Michael Rainey reported that Medicare is shaping up as one of the most important issues in the 2020 election, with several leading Democrats offering proposals that would significantly expand the program. President Trump jumped into the fray with an executive order last week that he claimed would protect and improve the Medicare system, in part by promoting broader use of private Medicare Advantage plans. Those plans are quite lucrative for the private insurers that sell them, Bloomberg’s John Tozzi said Wednesday, and they’ll be pushing hard to sell more of them when Medicare enrollment begins next week.

Enrollment in Medicare Advantage has more than tripled in the last 20 years, and now about a third of all Medicare beneficiaries get coverage through private plans. If current trends continue, more than half of all beneficiaries will be in Medicare Advantage by 2025, according to Tozzi.

How it works: Those who sign up for Medicare Advantage pay the same monthly premiums as regular plans but agree to certain limits imposed by the insurers, such as a restricted network of doctors, and also receive a wider range of benefits, which can include drugs plans and dental care. Insurers get a fee from the government for each person who signs up and is responsible for managing their plans to ensure a profit. In 2019, the average fee for each of the roughly 22 million participants was $11,545 – which comes to a total of about $254 billion.

Big numbers for insurers: Insurers see Medicare Advantage as “as a lucrative market they can’t afford to pass by,” Tozzi said, especially as sales of traditional, employer-based insurance plans slow. Medicare is now the biggest part of UnitedHealthcare’s business and the insurance giant is expanding to reach 90% coverage of the market next year. Other major players including Humana and Aetna are also expanding their coverage, and competition in the space is growing.

More generous benefits: Recent rule changes have allowed private insurers to offer new benefits within Medicare Advantage, such as meal delivery, air-conditioners, and in-home help. Regular fee-for-service Medicare doesn’t offer such options due to concerns about fraud.

A potential political battle ahead: Insurers increasingly rely on the revenues and profits from Medicare Advantage and can be expected to fight any effort to restrict – or, as some Democrats are calling for, eliminate – the existing private system. And as the plans become more generous – and, as critics have pointed out, more expensive for the government – seniors are likely to resist changes as well, complicating any Democratic effort to enact sweeping changes in the Medicare system.

Targeting ‘Medicare For All’ Proposals, Trump Lays Out His Vision For Medicare

Selena Simmons reported that President Trump gave a speech and signed an executive order on health care Thursday, casting the “Medicare for All” proposals from his Democratic rivals as harmful to seniors.

His speech, which had been billed as a policy discussion, had the tone of a campaign rally. Trump spoke from The Villages, a huge retirement community in Florida outside Orlando, a deep-red part of a key swing state.

His speech was marked by cheers, standing ovations and intermittent chants of “four more years” by an audience of mostly seniors.

Trump spoke extensively about his administration’s health care achievements and goals, as well as the health policy proposals of Democratic presidential candidates, which he characterized as socialism.

The executive order he signed had previously been titled “Protecting Medicare From Socialist Destruction” on the White House schedule but has since been renamed “Protecting and Improving Medicare for Our Nation’s Seniors.”

“In my campaign for president, I made you a sacred pledge that I would strengthen, protect and defend Medicare for all of our senior citizens,” Trump told the audience. “Today I’ll sign a very historic executive order that does exactly what — we are making your Medicare even better, and … it will never be taken away from you. We’re not letting anyone get close.”

The order is intended, in part, to shore up Medicare Advantage, an alternative to traditional Medicare that’s administered by private insurers. That program has been growing in popularity, and this year, premiums are down and plan choices are up.

The executive order directs the Department of Health and Human Services to develop proposals to improve several aspects of Medicare, including expanding plan options for seniors, encouraging innovative plan designs and payment models and improving the enrollment process to make it easier for seniors to choose plans.

The order includes a grab bag of proposals, including removing regulations “that create inefficiencies or otherwise undermine patient outcomes”; combating waste, fraud, and abuse in the program; and streamlining access to “innovative products” such as new treatments and medical devices.

The president outlined very little specific policy in his speech in Florida. Instead, he attacked Democratic rivals and portrayed their proposals as threatening to seniors.

“Leading Democrats have pledged to give free health care to illegal immigrants,” Trump said, referring to a moment from the first Democratic presidential debate in which all the candidates onstage raised their hands in support of health care for undocumented migrants. “I will never allow these politicians to steal your health care and give it away to illegal aliens.”

Health care is a major issue for voters and is one that has dominated the presidential campaign on the Democratic side. In the most recent debate, candidates spent the first-hour hashing out and defending various health care proposals and visions. Only two candidates, Sen. Bernie Sanders, and Sen. Elizabeth Warren — between a Medicare for All system — support the major divide and a public option supported by the rest of the field.

Trump brushed those distinctions aside. “Every major Democrat in Washington has backed a massive government health care takeover that would totally obliterate Medicare,” he said. “These Democratic policy proposals … may go by different names, whether it’s single-payer or the so-called public option, but they’re all based on the totally same terrible idea: They want to raid Medicare to fund a thing called socialism.”

Toward the end of the speech, he highlighted efforts that his administration has made to lower drug prices and then suggested that drugmakers were helping with the impeachment inquiry in the House of Representatives. “They’re very powerful,” Trump said. “I wouldn’t be surprised if … it was from some of these industries, like pharmaceuticals, that we take on.”

Drawing battle lines through Medicare may be a savvy campaign move on Trump’s part.

Medicare is extremely popular. People who have it like it, and people who don’t have it think it’s a good thing too. A recent poll by the Kaiser Family Foundation found that more than 8 in 10 Democrats, independents and Republicans think of Medicare favorably.

Trump came into office promising to dismantle the Affordable Care Act and replace it with something better. Those efforts failed, and the administration has struggled to get substantive policy changes on health care.

On Thursday, administration officials emphasized a number of its recent health care policy moves.

“[Trump’s] vision for a healthier America is much wider than a narrow focus on the Affordable Care Act,” said Joe Grogan, director of the White House’s Domestic Policy Council, at a press briefing earlier.

The secretary of health and human services, Alex Azar, said at that briefing that this was “the most comprehensive vision for health care that I can recall any president putting forth.”

He highlighted a range of actions that the administration has taken, from a push on price transparency in health care to a plan to end the HIV epidemic, to more generic-drug approvals. Azar described these things as part of a framework to make health care more affordable, deliver better value and tackle “impassable health challenges.”

Without a big health care reform bill, the administration is positioning itself as a protector of what exists now — particularly Medicare.

“Today’s executive order particularly reflects the importance the president places on protecting what worked in our system and fixing what’s broken,” Azar said. “Sixty million Americans are on traditional Medicare or Medicare Advantage. They like what they have, so the president is going to protect it.”

Trump’s New Order For Medicare Packs Potential Rise In Patients’ Costs

Julie Appleby reported that vowing to protect Medicare with “every ounce of strength,” President Donald Trump last week spoke to a cheering crowd in Florida. But his executive order released shortly afterward includes provisions that could significantly alter key pillars of the program by making it easier for beneficiaries and doctors to opt-out.

The bottom line: The proposed changes might make it a bit simpler to find a doctor who takes new Medicare patients, but it could lead to higher costs for seniors and potentially expose some to surprise medical bills, a problem from which Medicare has traditionally protected consumers.

“Unless these policies are thought through very carefully, the potential for really bad unintended consequences is front and center,” said economist Stephen Zuckerman, vice president for health policy at the Urban Institute.

While the executive order spells out few details, it calls for the removal of “unnecessary barriers” to private contracting, which allows patients and doctors to negotiate their own deals outside of Medicare. It’s an approach long supported by some conservatives, but critics fear it would lead to higher costs for patients. The order also seeks to ease rules that affect beneficiaries who want to opt-out of the hospital portion of Medicare, known as Part A.

Both ideas have a long history, with proponents and opponents duking it out since at least 1997, even spawning a tongue-in-cheek legislative proposal that year titled, in part, the “Buck Naked Act.” More on that later.

“For a long time, people who don’t want or don’t like the idea of social insurance have been trying to find ways to opt-out of Medicare and doctors have been trying to find a way to opt-out of Medicare payment,” said Timothy Jost, emeritus professor at Washington and Lee University School of Law in Virginia.

The specifics will not emerge until the Department of Health and Human Services writes the rules to implement the executive order, which could take six months or longer. In the meantime, here are a few things you should know about the possible Medicare changes.

What are the current rules about what doctors can charge in Medicare?

Right now, the vast majority of physicians agree to accept what Medicare pays them and not charge patients for the rest of the bill, a practice known as balance billing. Physicians (and hospitals) have complained that Medicare doesn’t pay enough, but most participate anyway. Still, there is wiggle room.

Medicare limits balance billing. Physicians can charge patients the difference between their bill and what Medicare allows, but those charges are limited to 9.25% above Medicare’s regular rates. But partly because of the paperwork hassles for all involved, only a small percentage of doctors choose this option.

Alternatively, physicians can “opt-out” of Medicare and charge whatever they want. But they can’t change their mind and try to get Medicare payments again for at least two years. Fewer than 1%of the nation’s physicians have currently opted out.

What would the executive order change?

That’s hard to know.

“It could mean a lot of things,” said Joseph Antos at the American Enterprise Institute, including possibly letting seniors make a contract with an individual doctor or buy into something that isn’t traditional Medicare or the current private Medicare Advantage program. “Exactly what that looks like is not so obvious.”

Others said eventual rules might result in lifting the 9.25% cap on the amount doctors can balance-bill some patients. Or the rules around fully “opting out” of Medicare might ease so physicians would not have to divorce themselves from the program or could stay in for some patients, but not others. That could leave some patients liable for the entire bill, which might lead to confusion among Medicare beneficiaries, critics of such a plan suggest.

The result may be that “it opens the door to surprise medical billing if people sign a contract with a doctor without realizing what they’re doing,” said Jost.

Would patients get a bigger choice in physicians?

Proponents say allowing for more private contracts between patients and doctors would encourage doctors to accept more Medicare patients, partly because they could get higher payments. That was one argument made by supporters of several House and Senate bills in 2015 that included direct-contracting provisions. All failed, as did an earlier effort in the late 1990s backed by then-Sen. Jon Kyl (R-Ariz.), who argued such contracting would give seniors more freedom to select doctors.

Then-Rep. Pete Stark (D-Calif.) opposed such direct contracting, arguing that patients had less power in negotiations than doctors. To make that point, he introduced the “No Private Contracts To Be Negotiated When the Patient Is Buck Naked Act of 1997.”

The bill was designed to illustrate how uneven the playing field is by prohibiting the discussion of or signing of private contracts at any time when “the patient is buck naked and the doctor is fully clothed (and conversely, to protect the rights of doctors, when the patient is fully clothed and the doctor is naked).” It, too, failed to pass.

Still, the current executive order might help counter a trend that “more physicians today are not taking new Medicare patients,” said Robert Moffit, a senior fellow at the Heritage Foundation, a conservative think tank based in Washington, D.C.

It also might encourage boutique practices that operate outside of Medicare and are accessible primarily to the wealthy, said David Lipschutz, associate director of the Center for Medicare Advocacy.

“It is both a gift to the industry and to those beneficiaries who are well off,” he said. “It has questionable utility to the rest of us.”

Elizabeth Warren Has Many Plans, But on Health Care, She’s ‘With Bernie’

Sahil Kaput noted that Elizabeth Warren has a plan for everything — but on the crucial 2020 issue of health care, she’s borrowing from a rival and fellow progressive — Bernie Sanders.

The presidential candidate who made a mark with her signature “I have a plan for that!” is the only one of the five top-polling Democrats without a sweeping proposal of her own to remake the health care system. She has instead championed Sanders’ legislation to replace private insurance by putting every American in an expanded Medicare program.

“I’m with Bernie on Medicare for All,” Warren said recently in New Hampshire when asked if she’d devise a blueprint of her own. “Health care is a basic human right. We need to make sure that everybody is covered at the lowest possible cost, and draining money out for health insurance companies to make a lot of profits, by saying no.”

Warren’s deference to a rival is unusual for a candidate who has styled herself as the policy wonk with a program for everything from cradle to grave. It has allowed her to attract many liberal voters who supported Sanders in 2016, leading her to a dead heat with former vice president Joe Biden for the top spot in the Democratic field. And if Sanders were to eventually drop out of the race before Warren, her embrace of his most popular plan could keep his supporters in her camp.

Sean McElwee, a left-wing activist, and researcher with Data For Progress said that Warren cannot afford to go soft on Medicare for All.

“It’s the best option for the campaign to stay in alignment with Sanders on health care through the general election,” he said. “These Sanders voters have the highest risk of voting third party or staying home, and you have to keep them mobilized.”

Weeks before Warren, a Massachusetts senator, announced that she was exploring a presidential run last December, she sounded less wedded to the Sanders proposal, describing a three-step approach to health care.

“Our first job is to defend the Affordable Care Act. Our second is to improve it and make changes, for example to families’ vulnerability to the impact of high-priced drugs,” she told Bloomberg News. “And the third is to find a system of Medicare available to all that will increase the quality of care while it decreases the cost of all of us.”

As Warren was rising in the polls, her allies began to pick up signals that Sanders supporters were questioning her commitment to progressive ideas. Since June, Warren has given them little ammunition to claim she’s going soft on Medicare for All, a defining issue for many left-wing voters.

“The biggest concern Warren has from the left is this idea that, at the end of the day, Sanders is the one true progressive,” McElwee said. “If your main issue is Medicare for All, and that’s a central tenet of your politics, Warren probably can’t win you. But she doesn’t want you to hate her. She wants to be your fallback option.”

At the same time, Warren faces attacks from Biden for supporting a plan that would replace Obamacare, which Democrats bitterly fought for in 2009 and 2010. “The senator says she’s for Bernie. Well, I’m for Barack,” the former vice president said in the third Democratic debate in September. “I think Obamacare worked.”

Biden’s plan would build out Obamacare and have a public option for those who want it.

Health care consistently ranks as the top issue for Democratic voters. Government-run health care is popular among Democrats and Americans overall, but that support dips once voters are given the arguments against it, including that it would require higher middle-class taxes and abolish employer-sponsored coverage.

Medicare for All, which lay at the heart of Sanders’ stronger-than-expected 2016 campaign, has become a litmus test for some progressive activists and voters. To them, it indicates a candidate’s belief in universal health care and willingness to take on private insurers who they say are gouging consumers for profit.

In Los Angeles on Friday, Warren was asked if her health care vision would raise middle-class taxes. She evaded the question and said working families would see their overall medical costs reduced, referring to the end of premiums and out-of-pocket expenses. “The very wealthy and big corporations will see their costs go up, but middle-class families will see their costs go down,” she said.

Surveys show that Sanders voters clearly prefer Warren as their second choice. But it doesn’t cut both ways — Warren’s supporters are more split among Sanders, Biden and Kamala Harris as their second choice.

Mary Anne Marsh, a Democratic consultant based in Boston, said that if Warren believes Sanders has the best plan, she has to “be all in on it — and if she’s got elements of her own to put in it, she needs to do that.”

The Sanders health care plan tracks with the “big structural change” Warren has called for, a message that also appeals to mainstream Democrats who backed Hillary Clinton in 2016. Maintaining that cross-section of support is critical to Warren’s path to the nomination. Biden is dominating with moderate and conservative Democrats, some of whom worry that running on Medicare for All will cost Democrats the general election.

“By supporting Bernie Sanders’ health care plan, Elizabeth Warren improves the chances of Bernie Sanders voters supporting her if she’s the nominee, thereby avoiding some for the heartburn Bernie gave Clinton and her supporters all the way through Election Day,” Marsh said.

A voter at her event in Keene, New Hampshire, asked Warren how she would handle the transition from private insurance to a government-run system.

“What we’ve got on Medicare for All is a framework,” she said. “And it doesn’t have the details, and you’re right to be antsy.”

To contact the reporter on this story: Sahil Kapur in Washington at skapur39@bloomberg.net

To contact the editors responsible for this story: Wendy Benjaminson at wbenjaminson@bloomberg.net, John Harney

Pete Buttigieg explains why he’s against Medicare for All

As reported by Adriana Belmont, Mayor Pete Buttigieg stands apart from other Democratic presidential candidates when it comes to health care policy. Unlike frontrunners Sens. Bernie Sanders (I-VT) and Elizabeth Warren (D-Mass.), he does not support for Medicare for All, but rather an alternative.

“I am a candidate who believes Medicare for All is not as attractive as Medicare for All Who Want It,” Buttigieg said at The New Yorker Festival. “Because it gives people a choice.”

Through Buttigieg’s plan, everyone would automatically be involved in universal health care coverage for those who are eligible. It would also expand premium subsidies for low-income individuals, cap out-of-pocket costs for seniors on Medicare, and limit what health care providers charge for out-of-network care at double what Medicare pays for the same service. However, those who still want to stay on private insurance can do so.

When asked whether or not this is a matter of “having your cake and eating it too,” Buttigieg responded: “Why not?”

“This is how public alternatives work,” Buttigieg said. “They create a public alternative that the private sector is then forced to compete with.”

This differs from other candidates like Sanders and Warren, both vocal supporters of a single-payer health system. Sanders has even gone so far as to call for the elimination of private insurance companies. Buttigieg, however, sees his plan as an opportunity for private insurance companies to step up.

“The way I come at it is with a certain humility about what’s going to happen,” Buttigieg said. “Because one of two things will happen. Either, there’s really no private option that’s as good as the public one we’re going to create … which means pretty soon everyone migrates to it and pretty soon it’s Medicare for all.”

“Or, some private plans are still better, in which case we’re going to be really glad we didn’t command the American people to abandon them whether they want to or not,” Buttigieg said. “I’m neutral on which one of those outcomes happen.”

According to Politico, although there is no official cost for what Medicare for All Who Want It would cost, a campaign adviser said the federal spending would “be in the ballpark” of $790 billion.

“The core principle is not whether or not the government is your health insurance provider,” Buttigieg said. “The core principle for me is you get covered one way or the other. That’s what Medicare for All Who Want It entails.”

Bernie Sanders admits he was ‘dumb’ for ignoring symptoms ahead of heart attack

Sen. Bernie Sanders (I-Vt.) is turning his heart attack into a PSA.

The 2020 candidate was hospitalized last week with what his doctors later said was a heart attack, leading Sanders to suspend his campaign events and a forthcoming Iowa ad buy. Sanders hasn’t said if he’ll resume campaigning before the Oct. 15 primary debate, but he does have a universally agreeable message in the meantime.

Sanders gave a health update at his home on Tuesday, telling reporters he was on his way to meet with a new cardiologist. “I must confess, I was dumb,” he said. Despite being “born” with “a lot of energy” and usually handling multiple rallies a day without a problem, “in the last month or two,” Sanders said he’d been “more fatigued than I usually have been.” “I should’ve listened to those symptoms,” Sanders continued, and then advised listeners to do the same “when you’re hurting when you’re fatigued when you have pain in your chest.”

Bernie Sanders is meeting a cardiologist this morning. A new doctor he has not met with before. Before he left he told reporters that he was “dumb” and should’ve listened to the warning signs his body was sending him prior to his heart attack.

Sanders first tied his hospitalization to his campaign in a tweet last week expressing his thanks for “well wishes,” “great doctors,” and “good health care.” “No one should fear going bankrupt” if they experience a medical emergency, he continued, and added in a call for “Medicare for All!”

What a dumb comment but it seems to follow how dumb Bernie is to neglect his heart disease however, he is telling us all about health care. And remember that Bernie has Congressional Blue Cross Blue Shield health care insurance, the best in the world!