The Further Punishment of Poverty
The entirety of Republican attacks on Obamacare, Medicare and Medicaid, which together underwrite health services for otherwise uninsured Americans, is that there is too much waste and fraud in the system.
That is the justification for voting a budget that demands $880 billion reductions in Medicare and Medicaid over the next years, in part to pay for permanent tax cuts favoring corporations and the wealthy and other Donald Trump spending plans for weapons and mass deportations. The spending cuts reach into research, services to veterans, and to state health fund assignments, a wide-enough net that it can be difficult or limiting to stop only at the bounds of one program when considering the overall impact on health.
It is a strategy coming to a head in Congress, in part because even Republicans realize that the math doesn’t work with political popularity.
In various recent remarks, Speaker Mike Johnson has doubled down, telling The Bulwark, “We have to root out fraud, waste, and abuse” in health spending. “We have to eliminate people on, for example, on Medicaid who are not actually eligible to be there — able-bodied workers, for example, young men who are — who should never be on the program at all.”
Other Republicans, including Trump, specify that all will be fine once we eliminate non-citizens from Medicaid coverage, skipping the fact that only lawful green card holders deemed permanent residents, refugees or asylees are eligible for such aid. (State rules vary, but only selected groups of “qualified non-citizens” can receive Medicaid, by income limits.)
But that’s the program: Drop able-bodied workers without dependents and the assumed undocumented patient population. In other words, they want to reduce eligible individual patients.
It’s an easy political target, not a formula to rid fraud and waste. It’s a way to further punish poverty.
What those statements ignore is that what Republicans are seeking is a huge downgrading of health services sought under the Affordable Care Act through Medicaid extensions among the states. The bill was enacted to add people to the rolls of health coverage, not to add to the millions of uninsured.
More directly, they skip the biggest source of prosecuted fraud in these programs — corporations who promote private Medicaid Advantage plans.
The Numbers
Medicare/Medicaid fraud generally involves intentional submission of false information to get benefits. It can take various forms, including billing for services not provided, double billing, upcoding and using false reports, and can result in prosecution and punishments from fines to jail.
In 2024, Medicaid fraud and improper payments totaled $31.1 billion, according to a report from Georgetown University. This number, which also includes billing errors, represents an improper payment rate of 5%, down from 8.6% in 2023.
It’s a relative drop when compared with what the Republican Congress wants to erase.
The study found that most Medicaid fraud is committed by providers — big insurance companies — not individual patients, regardless of their ableness or immigrant status.
Even the government inspectors say there are no reliable estimates of the amount of fraud against Medicaid, but the Justice Department and inspectors general for the Health and Human Services Depart have an annual report that identify who the bad actors are. The December 2024 report lists examples fraud against Medicaid moving towards prosecution that include ambulance service providers, durable medical equipment suppliers, diagnostic labs, nursing homes, pain clinics, pharmacies, physical therapists, physicians, and substance use treatment providers. No patients are in the listing.
The HHS inspectors’ summary of state fraud violations in a May 2024 report similarly shows prosecutions against a variety of providers, not individual patients.
The Congressional Budget Office estimates that 34 million able-bodied adults were enrolled in Medicaid in 2024 without any work requirements in place. When a bill arose setting requirements that eligibility turn on work, looking for work or disability, the CBO estimated savings of $135 billion over nine years.
In short, it makes for wonder about the math that Republicans are using.
Why Not Follow the Fraud?
If attention wants to focus on fraud, recent prosecutions suggest a better target are the insurance companies that heavily promote Medicare Advantage programs
Almost half of Medicare beneficiaries have a private Medicare Advantage plan, a system devised by Congress as a private-sector alternative to traditional Medicare to provide better care at lower cost. As with HMOs, the Advantage plans usually offer more consumer services through member doctors and health providers.
It turns out that most large insurers in the program have been accused in court of fraud, The Wall Street Journal and The New York Times reported in 2022.
Lawsuits showed that the insurance companies often submitted diagnoses by the government for more serious diseases than patients were exhibiting. This allowed insurers to collect more money from the federal government in ways that have allowed companies to inflate profits by billions of dollars. Basically, the government pays Medicare Advantage insurers a set amount for each person who enrolls, with higher rates for sicker patients. Insurers are incented to make their patients appear as sick as possible, often without providing additional treatment, according to the lawsuits.
As a result, a program devised to help lower health care spending has instead become substantially more costly than the traditional government program it was meant to improve. According to The Times, Wall Street Journal and NPR, eight of the 10 biggest Medicare Advantage insurers — representing more than two-thirds of the market — have submitted inflated bills, according to the federal audits. Four of the five largest players — UnitedHealth, Humana, Elevance and Kaiser — have faced federal lawsuits alleging that efforts to over-diagnose their customers crossed the line into fraud.
An example might be a cataract patient with diabetes getting diagnoses with diabetes complications, triggering thousands of dollars or more payments a year.
CBS News has noted that efforts to draft stricter oversight of Medicare Advantage insurers have failed in the ensuing wail from insurance companies. Even a decade ago, The Centers for Medicare & Medicaid Services published draft regulations to require health plans to identify overpayments by CMS and refund them to the government, but the idea dropped without explanation. Subsequent court filings showed that agency officials repeatedly cited concern about pressure from the industry.
The 2014 decision by CMS, and events related to it, are at the center of a multibillion-dollar Justice Department civil fraud case against UnitedHealth Group pending in federal court in Los Angeles.
As with the larger societal swipe against immigrants over crime, national security questions and public funds, Republican leadership is too fixated on a social, cultural goal than to solve even the problems they identify.
If you really need to cut health funds, why not start where the problems seem to lie rather than inventing new ones that can’t add up to a solution?
CLICK TO DONATE IN ORDER TO HELP US HELP PROTECT YOUR RIGHTS
1 Comment
The big fraud always comes from the big money players, not the little guys, but it is the little guys who pay.