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Project 2025's Plan to Kill Medicare Via Default Enrollments in For-Profit Alternative
"If implemented, Project 2025 would lead to a multibillion-dollar annual giveaway to corporations at the expense of Medicare enrollees and taxpayers," warns a new Center for American Progress report.
Aug 15, 2024
Project 2025—the far-right initiative to expand U.S. presidential power and purge the federal civil service—poses a dire threat to the government-run healthcare coverage enjoyed by tens of millions of senior citizens by making private, for-profit Medicare Advantage plans the default option for all Medicare enrollees, a report published Thursday warned.
The Center for American Progress (CAP) report said the goal of the Heritage Foundation and other right-wing groups behind Project 2025 involves "pushing the United States toward a future of fully privatized Medicare."
"If implemented, Project 2025 would lead to a multibillion-dollar annual giveaway to corporations at the expense of Medicare enrollees and taxpayers, and at the expense of Medicare's financial sustainability," CAP said, noting that "Medicare Advantage costs the Medicare program 22% more per enrollee than traditional Medicare."
"If Project 2025's plan to make MA the default option were to expand the proportion of Medicare beneficiaries in MA to 75%—up from its current enrollment level of 51%—CAP estimates that wasteful spending could approach an eye-popping $2 trillion over 10 years," the publication states.
Furthermore, the report says that "making Medicare Advantage the default option would restrict more Medicare enrollees' options over which doctors and hospitals they can receive care from."
Report co-author and CAP research associate for health policy Brian Keyser said in a statement that "Project 2025's plan to make Medicare Advantage the default option would give corporations even more power and strip doctors and patients of the freedom to make decisions about what care enrollees can or cannot receive."
"Project 2025's plan makes it clear—its priority is to help boost profit-driven corporations' bottom lines at the expense of Medicare enrollees' access to care and the future solvency of Medicare," Keyser added.
Often derided as "Medicare Disadvantage" by critics, MA was created by a GOP-controlled Congress and signed into law in 2003 by then-President George W. Bush "as a way of routing hundreds of billions of taxpayer dollars into the pockets of for-profit insurance companies," according to frequent Common Dreams opinion contributor Thom Hartmann.
A report published last year by Physicians for a National Health Program revealed that MA plans are overcharging U.S. taxpayers by up to $140 billion per year, enough to completely eliminate Medicare Part B premiums or fully fund Medicare's prescription drug program.
The MA report is part of a CAP series on Project 2025—which also includes ananalysis from last week showing how the initiative "would make it easier for big corporations to dump dangerous toxins that poison Americans."
According to the report, the initiative's plan to dismantle environmental regulations—as former President Donald Trump, the 2024 GOP nominee, did during his first term—threatens to reverse progress in protecting Americans from toxins like lead, soot, and other poisons including per- and polyfluoroalkyl substances (PFAS), also known as "forever chemicals" because they don't break down easily over time.
In an attempt to distance himself from the extremist agenda, Trump has claimed that he "knows nothing about" Project 2025 or who is behind it.
However, at least 140 people who worked in the first Trump administration have been involved with Project 2025, and last week The Washington Post published an article revealing that Trump took a private jet flight with Heritage Foundation president Kevin Roberts to a conference where the GOP nominee said that the conservative think tank is "going to lay the groundwork and detail plans for exactly what our movement will do."
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Alarms Raised Over For-Profit Medicare Advantage Using AI to Deny Care to Seniors
"Insurers using AI to deny needed care to seniors and people with disabilities means sacrificing patient needs on the altar of corporate greed," said one campaigner.
Jun 25, 2024
Dozens of Democratic U.S. lawmakers joined consumer and patient advocates on Tuesday in sounding the alarm over the use of artificial intelligence by companies providing Medicare Advantage plans to deny healthcare to their senior customers.
Fifty-one Democratic members of Congress and Independent Sen. Bernie Sanders of Vermont wrote to Centers for Medicare and Medicaid Services (CMS) Administrator Chiquita Books LaSure on Tuesday expressing their concern over Medicare Advantage (MA) providers' increasing use of algorithmic systems to deny patient care.
"Plans continue to use AI tool to erroneously deny care and contradict provider assessment findings," the letter notes. "Last year, a class action lawsuit was filed alleging that UnitedHealth Group unlawfully used an AI algorithm, nH Predict, to deny rehabilitative care to sick Medicare Advantage patients."
"The lawsuit cites an investigation suggesting that UnitedHealth Group pressured employees to use the algorithm to issue payment denials to Medicare Advantage beneficiaries and set a goal for employees to keep patient rehabilitation stays within 1% of the length of stay predicted by nH Predict," the lawmakers continued.
MA plans are not part of Medicare. They are a private health insurance "scam" created by a Republican-controlled Congress and signed into law by then-President George W. Bush "as a way of routing hundreds of billions of taxpayer dollars into the pockets of for-profit insurance companies," according to frequent Common Dreams opinion contributor Thom Hartmann.
Advocates have warned about the use of AI in MA denials since at least last year, while imploring congressional and regulator action to protect seniors and people with disabilities from being preyed upon by what critics have called "Medicare disadvantage" companies.
In February, CMS "clarified that Medicare Advantage organizations may use algorithms, artificial intelligence, and related technologies to assist in making coverage determinations, but these technologies may not override standards related to medical necessity and other applicable rules for how coverage determinations by Medicare Advantage organizations are made."
Rights groups echoed the lawmakers' concerns about the use of AI for MA denials.
"Medicare Advantage insurers using AI to deny needed care to seniors and people with disabilities means sacrificing patient needs on the altar of corporate greed," Public Citizen executive vice president Lisa Gilbert said. "CMS must expand upon the steps it has already taken to improve oversight of companies using AI to deny care that would be covered by traditional Medicare."
"It is time to protect enrollees by cracking down on Medicare Advantage insurers using AI to deny needed care through additional reporting requirements and increased enforcement actions against bad actors," Gilbert added.
David Lipschutz, associate director of the Center for Medicare Advocacy, said in a statement that "in our experience, MA plans' use of AI or algorithmic software has led to more inappropriate denials and premature terminations of care—this must end."
A report published earlier this month revealed that MA plans have overcharged the federal government by $612 billion since 2007—and $82 billion last year alone. Another report published last year by Physicians for a National Health Program found that MA plans are also overcharging U.S. taxpayers by up to $140 billion per year, enough to erase all Medicare Part B premiums or fully fund Medicare's prescription drug program.
A 2022 U.S. Senate Finance Committee investigation found that insurance companies and other brokers are "running amok" with "fraudsters and scam artists" making false or misleading claims to dupe seniors into buying MA plans. In February 2023, Reps. Mark Pocan (D-Wis.), Ro Khanna (D-Calif.), and Jan Schakowsky (D-Ill.) reintroduced legislation to change the official name of MA to "alternative private health plan" to make clear that such coverage is offered by for-profit companies.
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'This Should Be a National Scandal': For-Profit Medicare Advantage Plans Using AI for Denials
"They're using AI to predict when to cut off payment for treatments," said one watchdog group. "We repeat, AI. Not a doctor."
Nov 03, 2023
As Medicare Advantage plans rely increasingly upon artificial intelligence to determine—and often deny—payment for patient care, a group of Democratic U.S. lawmakers on Friday urged Medicare's top official to strengthen oversight of AI and algorithmic tools used to make coverage determinations.
"In recent years, problems posed by prior authorization have been exacerbated by MA plans' increasing use of AI or algorithmic software to assist in their coverage determinations in certain care settings, including inpatient hospitals, skilled nursing facilities, and home health," 32 House Democrats led by Rep. Judy Chu (D-Calif.) wrote in a letter to Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Books LaSure.
"Advocates and the media report that the use of such software has led to coverage decisions that are more restrictive than allowed under traditional Medicare rules, as well as more frequent and repeated denials of care," the lawmakers wrote. "Absent prohibiting the use of AI/algorithmic tools outright, it is unclear how CMS is monitoring and evaluating MA plans' use of such tools in order ensure that plans comply with Medicare's rules and do not inappropriately create barriers to care."
The lawmakers are calling on CMS to take steps including, but not limited to:
- Requiring MA plans to report prior authorization data including reason for denial, by type of service, beneficiary characteristics (such as health conditions), and timeliness of prior authorization decisions;
- Comparing "guidance" generated by AI and algorithmic tools with actual MA coverage decisions;
- Assessing how and to what extent initial prior-authorized AI determinations for services are adjusted to account for unanticipated changes in a patients' condition;
- Requiring attestation from MA plans and contractors that their coverage guidelines are not more restrictive than traditional Medicare; and
- Determining whether MA plans are inappropriately using race/other factors in these algorithms.
MA plans are not part of Medicare. They are a private health insurance "scam" created by a GOP-controlled Congress and signed into law 20 years ago by then-President George W. Bush "as a way of routing hundreds of billions of taxpayer dollars into the pockets of for-profit insurance companies," according to frequent Common Dreams opinion contributor Thom Hartmann.
A report published last month by Physicians for a National Health Program revealed that MA plans are overcharging U.S. taxpayers by up to $140 billion per year, enough to completely eliminate Medicare Part B premiums or fully fund Medicare's prescription drug program.
The lawmakers' letter is endorsed by advocacy groups including the Center for Medicare Advocacy, Public Citizen, Social Security Works, Center for Health and Democracy, and Business Leaders for Health Care Transformation.
"The use of AI by Medicare Advantage insurers to deny needed care to seniors and people with disabilities represents the most recent and dangerous step by greedy companies focused on profit instead of patients," Public Citizen executive vice president Lisa Gilbert said in a statement.
"Now is the time for CMS to crack down on companies that are using AI and other mechanisms to deny care that would be covered if the enrollee were covered by traditional Medicare," Gilbert added. "Understanding how Medicare Advantage insurers are using AI to deny needed care and holding bad actors accountable are crucial steps to protecting seniors and the Medicare program."
Last year, a U.S. Senate probe found that insurance companies and other brokers are "running amok" with "fraudsters and scam artists" making false or misleading claims to dupe senior citizens into purchasing MA plans.
Progressive lawmakers have also criticized President Joe Biden for delaying promised curbs on Medicare Advantage plans amid heavy insurance industry lobbying.
Earlier this year, Reps. Mark Pocan (D-Wis.)—one of the 32 lawmakers who signed the letter to Brooks LaSure—Ro Khanna (D-Calif.), and Jan Schakowsky reintroduced a bill to change the official name of MA to "alternative private health plan" to make clear that such coverage is offered by for-profit companies.
"The scheme is called Medicare Advantage," Pocan and Khanna explained. "But in reality, so-called 'Medicare Advantage' is neither Medicare nor an advantage."
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