Note: Free xpostfactoid subscription is available on Substack alone, though I will continue to cross-post on this site. If you're not subscribed, please visit xpostfactoid on Substack and sign up.
 |
| Families USA launches a campaign |
The mood was grim but determined at Families USA’s Health Action 2026 conference in D.C. last week. Broadly speaking, the focus was dual: mitigating the harm wrought by Republicans’ $1 trillion-plus cuts to Medicaid and the ACA marketplace (and RFK Jr.’s perversion of federal public health agencies), and looking forward toward a positive agenda for making healthcare affordable for all Americans.
Mitigation is largely about slow boring on hard boards: state agencies riding herd on the managed care organization (MCOs) that run most of their Medicaid programs, and advocacy groups riding herd on state agencies to drive that accountability.
The forward-looking agenda was not about ultimate visions for the U.S. healthcare system, such as single-payer or “Medicare for all who want it.” Rather, the focus, mainly in the plenary session “Building the Health Care System We Deserve,” was on spotlighting the extent to which the drive to maximize profit permeates and corrupts all main sectors of the healthcare system — hospital systems and physician practices, insurance and pharma.
That spotlight was synced with a campaign Families USA kicked off with the conference, Stop the Bleed, which aims to challenge every candidate for office in 2026 to explain what they would do to contain healthcare costs — not just what individuals pay, but in what all payers collectively pay.
“Bleed” rhymes with “greed,” and Families USA vows that “Stop the Bleed will activate Families USA partners and advocates across the country to commit to asking candidates what their plans are for taking on corporate greed and bringing down health care costs.”
I would add, as a caveat, that if voters ask Republican candidates what they’ll do to cut healthcare costs, those candidates will mostly spout bullshit about cutting waste, fraud and abuse. They justified their savage cuts to Medicaid and the marketplace by asserting that they were just cutting eligibility for people who don’t deserve coverage — smearing lawfully present noncitizens who lack green cards as “illegals” and Medicaid expansion enrollees as “able-bodied” freeloaders diverting resources from the “truly vulnerable.” Families USA says it will report the results of participants’ candidate querying in April — presumably with some assessment of the quality and plausibility of their responses.
The diagnosis: pervasive profit-seeking
The plenary session on transforming the healthcare system was moderated by STAT’s Bob Herman, who has broken a series of stories about questionable revenue maximization at UnitedHealthcare — including deploying AI to increase denials for vital services to Medicare Advantage enrollees. When Herman asked what the chief drivers of relentlessly rising costs are, Shawn Grenninger, who represents employers in their purchase of health plans, answered shortly, “It’s hospitals” —noting that “half our spend goes to hospital systems.” (Presumably that includes hospital-owned physician practices, as more than half of practices are now hospital-owned.) He attributed their pricing power to consolidation — as did Sophia Tripoli, Senior Director of Health Policy at Families USA, who outlined the default business model of amassing power by buying the competition and raising prices. Manny Pastreich, President at SEIU Local 32BJ, pointed to hospitals buying doctors’ offices, then promptly increasing prices by 200-300%. He called for legislation capping doctors’ prices at historical rates. He also complained that there is no correlation between price and quality. Dr. Chris Pernell, Director at NAACP Center for Health Equity, cautioned that “affordability” is not just about price — it’s about quality, cultural fluency, communicating with patients to determine what they need rather than throwing a battery of tests at them.
As it was agreed that all industries in the system were geared to maximize revenue, Herman asked whether it was possible to get insurers, hospitals and pharma to acknowledge their shared culpability. The answer was essentially no. Grenninger said that he had tried repeatedly but could not convince the players that they are (part of) the problem: they all point fingers at one another. He noted in particular that “hospitals are good at sticking together” — whereas the large private (mostly nominally nonprofit) hospital systems are very well-heeled, and safety-net and rural hospitals are often on the edge, the AHA is good at uniting them against any constraint on pricing. He also admitted — what is really a chronic complaint of health system observers — that employers have not been effective in demanding lower prices.
With regard to drug prices, Tripoli spoke of the need to apply the inflation rebates enacted for Medicare Part D plans in the Inflation Reduction Act to commercial prices as well. Grenninger, noting pharma’s propensity to blame Pharmacy Benefit Managers for inflating prices, emphasized that hospitals are also middlemen that take their cut. (I inferred that he was referring primarily to Part B physician administered drugs. Herman noted in an after-conversation that hospitals also are purported to abuse of the 340b program, which requires manufacturers participating in Medicaid to sell drugs at discounts to eligible clinics and hospitals and permits them to charge market prices to all payers. The revenue from 340b is supposed to be used to increase service to low-income populations, but various government studies and audits have found widespread noncompliance.)
Grenninger added that the Medicare drug negotiation enacted in the IRA is vital to improving drug cost control — and noted that the Trump administration appears to have got on board with the program in year 2. That observation was in keeping with Grenninger’s earlier assertion that government attempts to curb costs in commercial markets are relatively nonpartisan (as is the weakness of such attempts). To the extent that is true, it suggests an opportunity for the Stop the Bleed campaign: pressure on candidates from both parties may help push movement on measures like curbing overpayment of Medicare Advantage plans through the risk adjustment program, or site-neutral payment reform (on which the Trump administration has taken a modest step). Tripoli and Grenninger both noted that Democrats as well as Republicans have failed to hold hospitals accountable for their revenue-maximizing practices.
Protecting Medicaid from OBBBA provisions
As mandated by HR1, the Republican megabill passed last July, Medicaid work requirements are scheduled to take effect on Jan. 1, 2027; Medicaid provider taxes are frozen and scheduled for a rate phase-down starting in 2028 in the 40 states (plus D.C.) that have enacted the ACA Medicaid expansion; and directed payments, by which states boost payment rates to hospitals, will be phased down beginning in 2028 to a resting point at 100% of Medicare rates in expansion states and 110% in nonexpansion states. A media-only session on what to expect in 2026 focused largely on mitigating the effect of work requirements, and a breakout session focused on Medicaid managed care under upcoming new regulation and payment limits.
In both sessions, speakers stressed that the Medicaid unwinding of 2023-24, during which states resumed eligibility redeterminations and disenrollments after a three-year pandemic-induced moratorium, served as a “dress rehearsal,” as Mary Beth Malcarney, Families USA’s chief Medicaid policy person, put it. In the media session, Anthony Wright stressed that states’ performance in the unwinding differed dramatically, with some states doing their utmost to keep eligible people enrolled (e.g., through “ex parte” renewal, or automatic renewal based on the state’s own data), while other states eagerly disenrolled as many people as quickly as possible. Looking ahead to the pending work requirements, Wright stressed that how states define and implement the many exemptions will be key; in particular, exemption for “medical frailty” will be a proving ground. He emphasized that CMS guidance as to exemptions is not out yet (an interim final rule is due June 1) — and whereas CMS under Trump might be expected to take a hard line, the administration made promises to a lot of advocacy groups representing people with various disabilities that exemption would be made easy.
The breakout session focused in part on techniques and factors that state agencies and advocacy groups could use to minimize disenrollments. John Kaelin, Advisor at Hilltop Institute at UMBC and a former executive at Centene, a major MCO, said that health plans have diagnostic data that could be deployed to grant exemptions, and that state agencies should apply pressure to MCOs to mine that data. As to communicating with enrollees — always challenging with a Medicaid population, where address changes are frequent — he said that the unwinding showed that texting is an effective type of outreach. Sue Berkowitz, Director of Policy at South Carolina Appleseed Legal Justice Center, noted that MCOs have an incentive to hold onto enrollees. Mary Beth Dyer, Senior Managing Director at Bailit Health, recalled that during the unwinding, CMS pressured states that were disenrolling people too quickly to restore some enrollees. She suggested that state agencies keep track of their MCOs’ enrollments and, if one MCO is losing more enrollees than the others, regard that as a red flag.
There was of course much more — on the nuts and bolts of pushing for progressive change in states through legislation (e.g., tax legislation, with federal funding cuts pending) and oversight of agencies, on recruiting constituents without partisan agendas to tell their stories and make their cases to elected officials in both parties, on building organizational capacity. As in every Health Action conference I’ve attended, I was heartened by exposure to the sinews of advocacy for progressive change — a sense that in a country where the rule of law and democracy are under assault, there is such a thick network of people and organizations that know how to make demands, apply pressure, and mobilize people. Whether this legacy of a mature democracy can withstand the sustained fascist effort to tear it all down remains an open question. But while the Trump administration and their allies and lackeys in Congress and state governments can tear down government capacity, they are also stimulating and strengthening citizen capacity to fight back.
No comments:
Post a Comment