UnitedHealth Group says it's cooperating with DOJ Medicare probe
July 24 (UPI) -- UnitedHealth Group said Thursday it is facing Department of Justice investigations over its Medicare billing practices.
UnitedHealth Group said in a statement on its website that it reached out to the DOJ after seeing media reports about investigations into its Medicare program.
"(UnitedHealth) has now begun complying with formal criminal and civil requests from the Department. The Company has full confidence in its practices and is committed to working cooperatively with the Department throughout this process," the statement said.
The insurer said it's launching its own investigation.
"To provide our stakeholders transparency and confidence (UnitedHealth) ... has proactively launched its own initiative to conduct third party reviews of policies, practices, and associated processes and performance metrics for risk assessment coding, managed care practices, and pharmacy services."
The company told CNBC that it expects to complete that review near the end of the third quarter.
The Wall Street Journal reported in May that the Justice Department is conducting a criminal investigation into UHC for Medicare fraud. The company said it stands "by the integrity of our Medicare Advantage program."
The Journal reported in July that the DOJ interviewed doctors about UnitedHealth's practices and asked if they felt pressured to submit claims for certain conditions that bolstered payments from the Medicare Advantage program.
"(UnitedHealth) is committed to maintaining the integrity of its business practices and serving as reliable stewards of American tax dollars," UnitedHealth said.
This is just the latest setback for the country's largest health insurer. Shares are down more than 42%, its CEO Andrew Witty left the company in May, it suffered a ransomware attack in early 2024, and then CEO Brian Thompson was killed in December 2024 by alleged shooter Luigi Mangione, which sparked significant public outrage against the company.
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Yahoo
12 minutes ago
- Yahoo
Insomnia is a global epidemic. How do we fix it?
On a special episode (first released on July 24th) of The Excerpt podcast: The question is: Why do we struggle to sleep? Jennifer Senior, a staff writer at The Atlantic, joins The Excerpt to talk about insomnia and what we can do about solving our sleep issues. Hit play on the player below to hear the podcast and follow along with the transcript beneath it. This transcript was automatically generated, and then edited for clarity in its current form. There may be some differences between the audio and the text. Podcasts: True crime, in-depth interviews and more USA TODAY podcasts right here Taylor Wilson: Hello, I'm Taylor Wilson, and this is a special episode of the Excerpt. According to a report released by the American Medical Association earlier this year, one-third of American adults experience acute insomnia, an inability to fall or stay asleep for several days at a time, but one in 10 adults suffer from chronic insomnia. That's an inability to fall or stay asleep three nights a week for three months or more. The condition has potentially debilitating health impacts, including an increased risk of depression, anxiety, substance abuse, and even car accidents. So the question is, why can't we sleep? Here to help me dig into the issue is Jennifer Senior, a staff writer at The Atlantic who recently went on her own journey to solve her insomnia and who shared her story in the magazine. Thank you for joining me, Jennifer. Jennifer Senior: Thanks for having me. Taylor Wilson: So let's start with I guess a 30,000-foot view of the issue. I know you spoke with a lot of sleep specialists, did a lot of independent research for your piece. Jennifer, what's the big picture here on American's trouble with sleep? Jennifer Senior: Right. Yeah. What's funny, I think the story was a little misnamed. I mean, this is really more story about, well, if you can't sleep, don't feel awful about it because there are so many shaming stories about people, whatever solutions people seek out. I do talk in the beginning about the way that the modern world absolutely conspires against sleep, that it just lays waste to your circadian rhythms. That people work two jobs, 16.4% of us work non-standard hours. If you're a white collar kind of professional, you've got these woodpecker like peck, peck, peck, incursions into your life all night and weekend long from your boss's work sort of never ends. I mean, we're just no longer yoked to the rhythms of the earth anymore. We're just part of this whirl of a wired world. Taylor Wilson: In the course of doing your research, was there something in particular that surprised you most about the problem? Jennifer Senior: I'll tell you what surprised me most, just generally. Whenever I interviewed any expert about this, and it didn't matter what species of expert, they could be an epidemiologist, they could be a neurologist, they could be a psychiatrist, they could be a clinician. Most of them said the same thing. There is a slight misconception that you need eight hours of sleep. There is some data saying this. There is another equally robust data set saying 6.5 to 7.4 is associated with the best health outcomes. Now it's very hard to tell. These studies are observational. They're not randomized. There was all sorts of confounds and problems with this, but this one study in particular had a million people in it. It's been replicated. There are plenty of people who believe this data and people vary. And over the course of a lifetime, your individual sleep capacity could change. In a funny way, that was what surprised me most. Right? This mantra, which is kind of a tyranny, get eight hours or else. Taylor Wilson: Well, you talked Jennifer about the modern world conspiring against us and our sleep, and I guess let's try to outline a few of the possible causes of what you call a public health emergency, right? What can you share with us here on this? Jennifer Senior: About other causes, you mean besides the kind of modernity itself and kids working on... Kids being assigned homework online, kids socializing online. I mean, adolescents are desperate for sleep. They're so hungry for it, and modern high schools and middle schools have them waking up preposterously early when their circadian rhythms are pitched forward. We've got a substantial sandwich generation that's taking care of young kids and their elderly parents. That's going to conspire against it. These are all immutable things. Also, there are elevated levels of anxiety now in our world, and anxiety itself is a huge source of... Or can be a source of sleeplessness, certainly can make one prone. So I mean, those are additional examples I suppose. Taylor Wilson: Let's talk through your story a bit here. When did you first realize that you had an issue with sleep? And walk us through your experience with insomnia. Jennifer Senior: It was 25 years ago and it was a very mysterious onset. I cannot tell you what brought it on to this day. It is a mystery. I had this extremely well-regulated kind of circadian clock. I fell asleep every night at 1:00. I woke up every day at 9:00. I lost my alarm clock. I still woke up at those times. I didn't have to buy a new alarm clock until I had an early flight one day, and yet sometime very close to my 29th birthday when virtually no circumstances in my life had changed one iota, I had a bad night, fell asleep at like 5:00. Thought nothing of it until they became more regular, and then I started doing all-nighters involuntarily, and I felt like I'd been poisoned. And to this day, I don't know what happened, but once that happens, the whole cycle starts to happen, then people suddenly become very afraid of not falling asleep and whatever kicked it off whether it's mysterious or known becomes irrelevant because then what you do is you start getting very agitated and going, oh my God, I'm not sleeping. Oh my God, I'm still not sleeping. Now it's 3:00 in the morning. Now it's 4:00 in the morning. Now it's 5:00 in the morning. Oh my God, I have one more hour, et cetera. Taylor Wilson: Well, you did write in the piece about the many different recommendations that she tried to solve your own sleep issues. What were some of them, Jennifer, and did any of them help? Jennifer Senior: Oh God, I tried all the things. This is before I sought real professional help, but I did all the things. I would took Tylenol PM, which did not work. I did acupuncture, which were lovely, but did not work. I listened to a meditation tape that a friend gave me, did not work. I listened to another one that was for sleep only that did not work. I ran. I always was a runner, but I ran extra, did not work. Gosh, changed my diet. I don't remember. I did all sorts of things. I tried different supplements, Valerian root, all these things. Melatonin, nothing, nothing. Taylor Wilson: You wrote in depth about one therapy that was recommended to you, and that was CBTI. That's cognitive based therapy for insomnia. Jennifer, first, what is this? And second, did you find any success by using this? Jennifer Senior: So cognitive behavioral therapy for insomnia, as you said, is the gold standard for treating insomnia. It's portable. You can take it with you. It's not like if you leave your sleep meds at home. The main tent pole of it, which is sleep restriction, which I'll get to in a minute, is very hard to do. I found it murder, the kind of easier parts, although they're still in a funny way, kind of paradoxical, are you have to change your thinking around this is the cognitive piece around sleeping and insomnia. You have to decide, okay, I'm not sleeping. So what? Now, this is kind of funny because there's this din surrounding us that says, oh my God, you're not sleeping. You're going to die of a heart attack. You're going to die of an immune disease. You're going to get cancer. All these things, right? You have to set that all aside and decide one more night's sleep that I can't sleep. So what? Right. That's one thing. You have to change your behaviors, deciding that you are going to consistently go to bed at the same time, wake up at the same time, all that, and not use your bed for anything other than just for sleeping and sex. The hard part and the most powerful part that I found it brutal was the part that said you have to restrict your sleep. If you had only five hours of sleep, but you're in bed for nine hours, you have to choose a wake-up time. Let's say it's 7:00 and then you have to go to bed five hours earlier, 2:00 to s7:00. That's all you can give yourself, and you cannot stop with that schedule until you've slept for the majority of those hours. That's very hard for a sleepless person. And then once you've succeeded, all you get to add on is 15 more minutes of sleep, and then you have to sleep the majority of those hours for three nights running. This is always for three nights running, and the idea is to build up a enough sleep pressure to regularize yourself. You basically capitulate to exhaustion and you start to develop a rhythm. I couldn't stick with it. I was so kind of stupid and depressed with sleeplessness by the time I started it that it probably was impractical and I refused to take drugs to help me fall asleep at the exact right hour, which many clinics recommend. If you're going to go to bed and sleep from 2:00 to 7:00, take something at 1:30 so that you fall asleep at two. But I was afraid of being dependent on drugs, and you can really wean yourself if you do it for a limited amount of time. You can wean yourself anytime really, if you're shrewd about it and if you taper. But I think that I would tell people to try it and to try it sooner rather than later, and to be unafraid of doing it in combination with drugs so that the schedule worked. Taylor Wilson: Well, I am happy you brought up drugs. I did want to bring that up just in terms of what experts are saying about their impact. Even just drugs and alcohol kind of writ large, but sleeping pills specifically. What did you find in researching this in terms of drugs and alcohol? Jennifer Senior: Well, there's a real stigma taking sleep medication, and I'm frankly a little sick of it. I'm not sure why this is so very stigmatized. Like, oh, they're drug addict. They're hooked on sleeping pills. It's framed as addiction, and no one says that someone is addicted to their Ozempic, even though a lifestyle change could perhaps obviate the need. No one says that they are addicted... Oh, that person is totally addicted to their blood pressure medication, even though maybe a change in lifestyle would help change that. Or that they're addicted to their statins, So I sort of bristle. And those who prescribe these medicines say like, look, if the benefit outweighs the risk and they're used properly, sometimes the real side effect is just being dependent on these drugs, and there's a difference between dependence and addiction. A surprisingly small number of people who take these drugs regularly, like benzodiazepines, like Ativan and Ambien and Klonopin, all these things, a surprisingly small number, like 7% increase their doses if they take it every night. So that's very small. However, there are cognitive decrements over time... Or not decrements. It can interfere with your memory and it can increase your odds of falling as you get older. And those are, to me, the real persuasive reasons to get off. Taylor Wilson: I want to back up a minute here to talk about something many may not be aware of, and that's that historically, at least in some eras, people used to sleep in two blocks. What do you know about this? How did this function and really why did this kind of sleep pattern work for some folks? Jennifer Senior: Well, it was sort of, I think, natural. It seemed that this is, and it has not been proven everywhere, but there's plenty of both historical evidence and also some in a lab by this wonderful guy named Tom Ware that shows that if you sort of just put someone in a room, 14 hours of darkness, what will happen is that their sleep will naturally split into two. They'll sleep for a phase, wake up for a phase, and then sleep for a phase again. And historically, there's all sorts of evidence that people would sleep for a phase, get up and read for a while, do some quiet things, do light tasks, maybe sing, maybe have sex, and then go back to bed. So there seemed to be two phases, and this was much easier to do when midnight was actually midnight. You were going bed when the sun had set, or just after were you were tethered to the rhythms of the earth as opposed to a wired electricity run world. Taylor Wilson: What is something you wish you knew when you first started on this journey? Jennifer Senior: To get on it earlier and to not be as afraid... Cognitive behavioral therapy is, I think, often done in conjunction with taking something like Klonopin or Ativan or Ambien, and I was so petrified of becoming hooked on them that I didn't... I refused to take them and I couldn't get my sleep to contract as a result of it. My body was so completely dysregulated and confused about it was so all over the place that I really needed something to regularize it and stabilize it, and I flipped out, and I think if anybody goes and tries CBT, I and their practitioner says to them, and I'm going to have to be on their recommendation, do this in concert with a drug, because you really need it. Don't sit there and freak out and think that you can't or shouldn't, because it happens a lot and people freak out a lot. Taylor Wilson: All right, Jennifer Senior, thank you so much for coming on the Excerpt. Jennifer Senior: Thank you so much for having me. Taylor Wilson: Thanks to our senior producers, Shannon Rae Green and Kaylee Monahan for their production assistance. Our executive producer is Laura Beatty. Let us know what you think of this episode by sending a note to podcasts@ Thanks for listening. I'm Taylor Wilson. I'll be back tomorrow morning with another episode of USA TODAY's the Excerpt. This article originally appeared on USA TODAY: Insomnia is a global epidemic. How do we fix it? | The Excerpt
USA Today
13 minutes ago
- USA Today
Insomnia is a global epidemic. How do we fix it?
On a special episode (first released on July 24th) of The Excerpt podcast: The question is: Why do we struggle to sleep? Jennifer Senior, a staff writer at The Atlantic, joins The Excerpt to talk about insomnia and what we can do about solving our sleep issues. Hit play on the player below to hear the podcast and follow along with the transcript beneath it. This transcript was automatically generated, and then edited for clarity in its current form. There may be some differences between the audio and the text. Podcasts: True crime, in-depth interviews and more USA TODAY podcasts right here Taylor Wilson: Hello, I'm Taylor Wilson, and this is a special episode of the Excerpt. According to a report released by the American Medical Association earlier this year, one-third of American adults experience acute insomnia, an inability to fall or stay asleep for several days at a time, but one in 10 adults suffer from chronic insomnia. That's an inability to fall or stay asleep three nights a week for three months or more. The condition has potentially debilitating health impacts, including an increased risk of depression, anxiety, substance abuse, and even car accidents. So the question is, why can't we sleep? Here to help me dig into the issue is Jennifer Senior, a staff writer at The Atlantic who recently went on her own journey to solve her insomnia and who shared her story in the magazine. Thank you for joining me, Jennifer. Jennifer Senior: Thanks for having me. Taylor Wilson: So let's start with I guess a 30,000-foot view of the issue. I know you spoke with a lot of sleep specialists, did a lot of independent research for your piece. Jennifer, what's the big picture here on American's trouble with sleep? Jennifer Senior: Right. Yeah. What's funny, I think the story was a little misnamed. I mean, this is really more story about, well, if you can't sleep, don't feel awful about it because there are so many shaming stories about people, whatever solutions people seek out. I do talk in the beginning about the way that the modern world absolutely conspires against sleep, that it just lays waste to your circadian rhythms. That people work two jobs, 16.4% of us work non-standard hours. If you're a white collar kind of professional, you've got these woodpecker like peck, peck, peck, incursions into your life all night and weekend long from your boss's work sort of never ends. I mean, we're just no longer yoked to the rhythms of the earth anymore. We're just part of this whirl of a wired world. Taylor Wilson: In the course of doing your research, was there something in particular that surprised you most about the problem? Jennifer Senior: I'll tell you what surprised me most, just generally. Whenever I interviewed any expert about this, and it didn't matter what species of expert, they could be an epidemiologist, they could be a neurologist, they could be a psychiatrist, they could be a clinician. Most of them said the same thing. There is a slight misconception that you need eight hours of sleep. There is some data saying this. There is another equally robust data set saying 6.5 to 7.4 is associated with the best health outcomes. Now it's very hard to tell. These studies are observational. They're not randomized. There was all sorts of confounds and problems with this, but this one study in particular had a million people in it. It's been replicated. There are plenty of people who believe this data and people vary. And over the course of a lifetime, your individual sleep capacity could change. In a funny way, that was what surprised me most. Right? This mantra, which is kind of a tyranny, get eight hours or else. Taylor Wilson: Well, you talked Jennifer about the modern world conspiring against us and our sleep, and I guess let's try to outline a few of the possible causes of what you call a public health emergency, right? What can you share with us here on this? Jennifer Senior: About other causes, you mean besides the kind of modernity itself and kids working on... Kids being assigned homework online, kids socializing online. I mean, adolescents are desperate for sleep. They're so hungry for it, and modern high schools and middle schools have them waking up preposterously early when their circadian rhythms are pitched forward. We've got a substantial sandwich generation that's taking care of young kids and their elderly parents. That's going to conspire against it. These are all immutable things. Also, there are elevated levels of anxiety now in our world, and anxiety itself is a huge source of... Or can be a source of sleeplessness, certainly can make one prone. So I mean, those are additional examples I suppose. Taylor Wilson: Let's talk through your story a bit here. When did you first realize that you had an issue with sleep? And walk us through your experience with insomnia. Jennifer Senior: It was 25 years ago and it was a very mysterious onset. I cannot tell you what brought it on to this day. It is a mystery. I had this extremely well-regulated kind of circadian clock. I fell asleep every night at 1:00. I woke up every day at 9:00. I lost my alarm clock. I still woke up at those times. I didn't have to buy a new alarm clock until I had an early flight one day, and yet sometime very close to my 29th birthday when virtually no circumstances in my life had changed one iota, I had a bad night, fell asleep at like 5:00. Thought nothing of it until they became more regular, and then I started doing all-nighters involuntarily, and I felt like I'd been poisoned. And to this day, I don't know what happened, but once that happens, the whole cycle starts to happen, then people suddenly become very afraid of not falling asleep and whatever kicked it off whether it's mysterious or known becomes irrelevant because then what you do is you start getting very agitated and going, oh my God, I'm not sleeping. Oh my God, I'm still not sleeping. Now it's 3:00 in the morning. Now it's 4:00 in the morning. Now it's 5:00 in the morning. Oh my God, I have one more hour, et cetera. Taylor Wilson: Well, you did write in the piece about the many different recommendations that she tried to solve your own sleep issues. What were some of them, Jennifer, and did any of them help? Jennifer Senior: Oh God, I tried all the things. This is before I sought real professional help, but I did all the things. I would took Tylenol PM, which did not work. I did acupuncture, which were lovely, but did not work. I listened to a meditation tape that a friend gave me, did not work. I listened to another one that was for sleep only that did not work. I ran. I always was a runner, but I ran extra, did not work. Gosh, changed my diet. I don't remember. I did all sorts of things. I tried different supplements, Valerian root, all these things. Melatonin, nothing, nothing. Taylor Wilson: You wrote in depth about one therapy that was recommended to you, and that was CBTI. That's cognitive based therapy for insomnia. Jennifer, first, what is this? And second, did you find any success by using this? Jennifer Senior: So cognitive behavioral therapy for insomnia, as you said, is the gold standard for treating insomnia. It's portable. You can take it with you. It's not like if you leave your sleep meds at home. The main tent pole of it, which is sleep restriction, which I'll get to in a minute, is very hard to do. I found it murder, the kind of easier parts, although they're still in a funny way, kind of paradoxical, are you have to change your thinking around this is the cognitive piece around sleeping and insomnia. You have to decide, okay, I'm not sleeping. So what? Now, this is kind of funny because there's this din surrounding us that says, oh my God, you're not sleeping. You're going to die of a heart attack. You're going to die of an immune disease. You're going to get cancer. All these things, right? You have to set that all aside and decide one more night's sleep that I can't sleep. So what? Right. That's one thing. You have to change your behaviors, deciding that you are going to consistently go to bed at the same time, wake up at the same time, all that, and not use your bed for anything other than just for sleeping and sex. The hard part and the most powerful part that I found it brutal was the part that said you have to restrict your sleep. If you had only five hours of sleep, but you're in bed for nine hours, you have to choose a wake-up time. Let's say it's 7:00 and then you have to go to bed five hours earlier, 2:00 to s7:00. That's all you can give yourself, and you cannot stop with that schedule until you've slept for the majority of those hours. That's very hard for a sleepless person. And then once you've succeeded, all you get to add on is 15 more minutes of sleep, and then you have to sleep the majority of those hours for three nights running. This is always for three nights running, and the idea is to build up a enough sleep pressure to regularize yourself. You basically capitulate to exhaustion and you start to develop a rhythm. I couldn't stick with it. I was so kind of stupid and depressed with sleeplessness by the time I started it that it probably was impractical and I refused to take drugs to help me fall asleep at the exact right hour, which many clinics recommend. If you're going to go to bed and sleep from 2:00 to 7:00, take something at 1:30 so that you fall asleep at two. But I was afraid of being dependent on drugs, and you can really wean yourself if you do it for a limited amount of time. You can wean yourself anytime really, if you're shrewd about it and if you taper. But I think that I would tell people to try it and to try it sooner rather than later, and to be unafraid of doing it in combination with drugs so that the schedule worked. Taylor Wilson: Well, I am happy you brought up drugs. I did want to bring that up just in terms of what experts are saying about their impact. Even just drugs and alcohol kind of writ large, but sleeping pills specifically. What did you find in researching this in terms of drugs and alcohol? Jennifer Senior: Well, there's a real stigma taking sleep medication, and I'm frankly a little sick of it. I'm not sure why this is so very stigmatized. Like, oh, they're drug addict. They're hooked on sleeping pills. It's framed as addiction, and no one says that someone is addicted to their Ozempic, even though a lifestyle change could perhaps obviate the need. No one says that they are addicted... Oh, that person is totally addicted to their blood pressure medication, even though maybe a change in lifestyle would help change that. Or that they're addicted to their statins, So I sort of bristle. And those who prescribe these medicines say like, look, if the benefit outweighs the risk and they're used properly, sometimes the real side effect is just being dependent on these drugs, and there's a difference between dependence and addiction. A surprisingly small number of people who take these drugs regularly, like benzodiazepines, like Ativan and Ambien and Klonopin, all these things, a surprisingly small number, like 7% increase their doses if they take it every night. So that's very small. However, there are cognitive decrements over time... Or not decrements. It can interfere with your memory and it can increase your odds of falling as you get older. And those are, to me, the real persuasive reasons to get off. Taylor Wilson: I want to back up a minute here to talk about something many may not be aware of, and that's that historically, at least in some eras, people used to sleep in two blocks. What do you know about this? How did this function and really why did this kind of sleep pattern work for some folks? Jennifer Senior: Well, it was sort of, I think, natural. It seemed that this is, and it has not been proven everywhere, but there's plenty of both historical evidence and also some in a lab by this wonderful guy named Tom Ware that shows that if you sort of just put someone in a room, 14 hours of darkness, what will happen is that their sleep will naturally split into two. They'll sleep for a phase, wake up for a phase, and then sleep for a phase again. And historically, there's all sorts of evidence that people would sleep for a phase, get up and read for a while, do some quiet things, do light tasks, maybe sing, maybe have sex, and then go back to bed. So there seemed to be two phases, and this was much easier to do when midnight was actually midnight. You were going bed when the sun had set, or just after were you were tethered to the rhythms of the earth as opposed to a wired electricity run world. Taylor Wilson: What is something you wish you knew when you first started on this journey? Jennifer Senior: To get on it earlier and to not be as afraid... Cognitive behavioral therapy is, I think, often done in conjunction with taking something like Klonopin or Ativan or Ambien, and I was so petrified of becoming hooked on them that I didn't... I refused to take them and I couldn't get my sleep to contract as a result of it. My body was so completely dysregulated and confused about it was so all over the place that I really needed something to regularize it and stabilize it, and I flipped out, and I think if anybody goes and tries CBT, I and their practitioner says to them, and I'm going to have to be on their recommendation, do this in concert with a drug, because you really need it. Don't sit there and freak out and think that you can't or shouldn't, because it happens a lot and people freak out a lot. Taylor Wilson: All right, Jennifer Senior, thank you so much for coming on the Excerpt. Jennifer Senior: Thank you so much for having me. Taylor Wilson: Thanks to our senior producers, Shannon Rae Green and Kaylee Monahan for their production assistance. Our executive producer is Laura Beatty. Let us know what you think of this episode by sending a note to podcasts@ Thanks for listening. I'm Taylor Wilson. I'll be back tomorrow morning with another episode of USA TODAY's the Excerpt.
Medscape
13 minutes ago
- Medscape
Medicare at 60: Successes, Failures
Sixty years ago, Congress passed legislation that created Medicare . In 1966, its first year of implementation, there were 19.1 million enrollees. Almost a decade later, enrollment had grown to 22.5 million. Today, 68.8 million Americans have Medicare coverage, with about half enrolled in Advantage plans. The original idea for this insurance program was even bigger, with President Harry Truman endorsing universal coverage in 1945. As Medicare turns 60, Medscape convened an expert panel to discuss the successes — and shortcomings — of this landmark insurance program. Jen Brull, MD: What do you all think the impact will be of the coming Medicaid cuts in the budget bill? For people who are dual eligible, who need help with shared costs, how do you think physicians might be affected if those patients lose access to Medicaid copays? Claudia M. Fegan, MD: The problem is that a lot of people think Medicaid cuts don't really affect me; I have private insurance. But as Norm alluded, there are going to be a lot of hospitals that close, especially rural hospitals. And as he said, when hospitals close, it puts stress on all the other hospitals that remain. And whether it's emergency room services or just services in general — women not having places to deliver babies — all of these things are going to have a tremendous impact. As for the dual-eligible patients, they are not the sharp edge of the point, right? Dual-eligible patients will have some challenges because of the amount that they can't pay. That 20% of healthcare costs is a lot of money to come up with, and it is going to be a problem in terms of being able to access their routine care and everyday care. But I think the more dramatic impact is going to be on services that are available in communities. I think even some outpatient facilities will close as a result. It's going to have a greater impact on the healthcare of everyone because it's going to be an access issue. Nursing Home Care Norman Ornstein, PhD: We have an enormous misunderstanding of what Medicaid is. People think it's a program for poor people, but it's far more than that. The single largest component is nursing home care. You make these cuts and nursing homes, many of which are also struggling, what are they going to do? Some will close. Others are going to cut back on the number of people serving their patients, and they're going to cut the rates at which they pay people. We are going to have people making the minimum wage, and we are going to see more and more elderly with bed sores, with abuse, and with other problems. Or we are going to see not just the elderly who use up their assets and have Medicaid to allow them to go into nursing homes, but the nightmare that families are going to have when the nursing home isn't there, and they will have to take their elderly parents or grandparents into their own homes and can't be reimbursed for any of the costs that they have or the stresses that it puts on their lives. We have a lot of issues here: the hospitals, the nursing homes. Also, we were talking before about the problems in Medicare Advantage, with prior authorization for an awful lot of people. I think it's not quite the same, but it's a little bit like these work requirements in Medicaid. The number of able-bodied people who are sitting back, cracking open a beer, and watching TV and taking their Medicaid because it doesn't cost them anything is, at best, a trace element. The tiny number of people — 3% or so — able-bodied people who are not working are taking care of other family members, or they have big health issues of their own. These work requirements are designed not to get those people working, but to take people off the Medicaid rolls because they're so complicated that people can't fill them out. They don't know what to do about them. This is going to have a devastating impact on a large number of Americans, and not just the poor. Jonathan Gruber, PhD: Let me just confirm what's been said and emphasize that three-quarters of Medicaid spending is for the elderly and disabled. Republicans want to pitch it as a program for undeserving minorities. That's not true. Almost everyone who gets Medicaid deserves it. It's a program for our moms and dads and everyone we know. We need to recognize that when Medicaid gets cut, everyone suffers. Ornstein: I just want to add one other thing that I think is important. I recently saw a documentary about the advent of the Americans with Disabilities Act, which was one of the most significant pieces of legislation to help people in this country. And it is now under siege. Jon had said, and Claudia said, disabled people are going to be devastated by this. Just yesterday [July 14] , the Supreme Court bizarrely allowed the President to go forward and cut the heart out of the Department of Education, which provides almost all of the support for students with special needs in the country. The people who are going to suffer more than anybody else in the country, other than many of the immigrants, are the disabled. And that's a problem for humanity. It is basic decency here that is under assault. That's true with a lot of these cuts in Medicaid. It's true that there will be a broader assault on people who can't care for themselves. Medicare's Influence on Independent Practice Brull: Dr Gruber, a survey of doctors by the American Medical Association in 2022 found that roughly 46% were working in practices wholly owned by physicians. The figure had fallen from 60% a decade prior. Dr Fegan, you referenced this earlier. In what ways has Medicare affected physicians' ability to remain independently owned? Gruber: I'm not sure that's been the primary driver. At the end of the day, the primary driver has been essentially the rise of the profit motivation in medicine. There's more money to be made by consolidating doctors into larger groups and specializing. That's not obviously bad; there are pros and cons of that movement, but I wouldn't say Medicare's really been a primary driver. I think the primary driver's been the fact that there's money to be made to this consolidation. The one thing to which Medicare has contributed is what I said before, which is that Medicare probably overpays subspecialists and underpays primary care. By combining them into one group, you can take advantage of that mismatch to have a more profitable overall group. Financial Uncertainty Brull: Dr Ornstein, back in 1999, the American Enterprise Institute wrote that analysts projected Medicare would reach insolvency in the following two decades, which would be now. But you also said that the first estimation of this came in the 1970s. A more recent projection from the board of trustees is 2036, so we kicked the can down a little bit. What do you think of this, and do you think it'll actually happen in the next 60 years? Ornstein: This program is so popular, for all the reasons that we know, that I just do not see Medicare becoming insolvent unless there's a deliberate attempt by those in government who want to undermine it to force insolvency. Otherwise, the closer you get, the more we're going to see fixes to make sure that the program can continue. We have seen efforts to eliminate Medicare, but they haven't gotten anywhere because of the enormous popularity of the program, for all the right reasons. So, we have to worry about it, but I'm not worried about it in the foreseeable future. Brull: Which aspects of Medicare's original mission do you think have either succeeded or fallen short, and why? Let's start with you, Dr Ornstein. Ornstein: I think the main reality here is that Medicare has saved enormous numbers of lives. It has made this country better all the way across the board. If there were no Medicare, we would have a hellscape for a large number of people — not just the elderly, but their children and their grandchildren. I would say it's also managed to deliver care pretty damned efficiently, more efficiently in many instances than the private system of insurance. There are gaps here. I think we have seen, and we continue to see, fraud because we haven't put enough resources into dealing with it, mostly on the provider side. I will just give you one very quick story. My wife has gotten from Medicare several times now a claim for a device she had nothing to do with, from a company. She spent hours on the phone with Medicare and they said, 'We know this company, it's horrible, we're going to take care of it.' Then 3 months later, we get it again and we get it a third time. We need to find more efficiencies. Gruber: I think the pros could not have been stated better by Norm. I mean, basically we would have a significantly more financially insecure country and less healthy country if Medicare didn't exist. As for the con, I would say that Medicare has not done enough to take advantage of its position as the dominant payer. There's fascinating economic research which shows that private payers often just follow what Medicare does. Pushing Health and Private Insurers Forward Gruber: Everybody talks about how the private sector is innovating, but in fact, all the innovation in medical compensation over the past 50 years has been by Medicare, and the private sector just copies them and pays X% of Medicare. I feel like Medicare could be much more innovative. Like I said, the physician reimbursement system is largely broken. Medicare could have invested a lot more — and should invest a lot more — in thinking about answering some of the hard questions we've raised today about what is the appropriate use of prior authorization, what are the appropriate rates to pay? These are important topics that Medicare should be taking the lead on understanding, experimenting with through CMMI [the Center for Medicare and Medicaid Innovation], which can run pilots, and actually trying to be much more innovative in how it sets payment policy. Fegan: I agree with both of the previous speakers. Medicare has succeeded in providing access to care to a very vulnerable population and has succeeded in providing assured compensation for the providers who take care of that population. It's one of the reasons why I've spent the past 30 years advocating for a Medicare for All that we could afford, to take care of the entire population with the program, with some improvements that we've alluded to during the discussion today. But Medicare has been a success. What it set out to do, which was to offer care and ensure that care would provide compensation for the people who delivered it — I think that we are a better society because of that. We certainly spend enough on healthcare in this country; we just fail to provide care to everyone who needs it. We allow too many people who are not engaged in the delivery of care to take profit from it. There's a lot of opportunity to address the fraud and abuse, and we just fail to do so. Part of the problem is because we have three healthcare lobbyists for every single member of Congress. Congress tends to hear those lobbyists over the cries of the public, which would really benefit from a universal healthcare system. Brull: Thank you all for joining us today and for such a productive discussion. We appreciate your time and expertise.
