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Rich Helppie The Common Bridge's avatar

The healthcare financing system is a mess. Nate Kaufman and I deconstruct Medicare Disadvantage and make recommendations on how to fix the system

https://thecommonbridge.substack.com/p/medicare-disadvantage

forumposter123@protonmail.com's avatar

People buy Medicare advantage because it’s cheaper. Cheaper plans have less coverage. This is Econ 101.

Do we really want healthcare to be 100% of gdp? If we don’t then at some point you’re going to have to forego some kind of healthcare people want. You can be direct about it (an actual denial) or indirect (so many providers won’t take Medicare or have huge wait lists because it doesn’t pay enough).

Anyway, giving old farts infinite care at infinite expense doesn’t strike me as a good deal for society.

Btw Medicare part d is one if the worst designed programs in the country with exponentially increasing costs, but I can see how an “everything should be free” guy would love it.

John Geis's avatar

“Anyway, giving old farts infinite care at infinite expense doesn’t strike me as a good deal for society.”

I think we should include others: let’s eliminate NIC Units. And cancer treatments. Let’s spread the pain around.

And BTW, that inheritance from your parents you were hoping for? Your parents’ doctor will be driving it around.

John Geis's avatar

“…so many providers won’t take Medicare or have huge wait lists because it doesn’t pay enough)”

You switched from talking about Medicare Advantage (Part C) to Medicare Parts A & B. If the above quote was about Part C, then you don’t what you’re talking about.

Medicare Part C has a completely different risk profile for providers. Your insurance company pays the providers, and Medicare pays the insurance company. The insurance company can add coverages beyond what Medicare will pay for, and those benefits affect the premium, of course. This puts the Part C patient on par with all other insurance patients from the providers’ perspective.

I’m a CPA and I know all of this from when our plan sponsor (my wife’s pre-retirement employer) 3 yrs ago switched from a “Parts A & B” plan to a Part C plan. I’ve also discussed with the insurance manager at 2 different doctor practices we use, and they both expressed a clear preference for dealing with insurance companies over Medicare.

forumposter123@protonmail.com's avatar

There are a lot of parts of the country were many providers won't take Medicare (Traditional or Part C) because the reimbursement rates are too low. They will either outright not take Medicare or they will tell you that it's a 24 month wait for new patients.

That's basically stealth rationing. You theoretically have a benefit but good luck actually using it.

"and they both expressed a clear preference for dealing with insurance companies over Medicare."

Many docs are in risk sharing arrangements with the Part C insurance companies where they get paid a bunch in bonuses if they can upcode the shit out of their patients. Costs the government a ton but its free money for all the other parties involved (providers, insurance, member).

John Geis's avatar

What’s your data source regarding Part C?

And I suppose if you buy a Yugo plan like we see on TV every November rather than from a “real” medical insurance company, you’re going to get Yugo results.

Upcoding fraud exists regardless of the payor, payee or medical plan of the patient. Do you have a data source for the Plan C fraud susceptibility accusation?

Geary Johansen's avatar

If you plug his last paragraph into an AI and ask it to substantiate the claim through actuarial analysis, then it will give you a pretty accurate picture of the tendency. It's large and the actuarial analysis picks up data which a standard audit won't find.

Diagnosis Harvesting, Condition Proliferation, and "Healthy Enrollee Upcoding" in Low-Risk Populations are all examples of practices which an audit won't pick up, but an actuarial analysis detects. Telehealth "check-ins" to add mild conditions is a particular problem.

John Geis's avatar

“If you plug his last paragraph into an AI and ask it to substantiate the claim through actuarial analysis, then it will give you a pretty accurate picture of the tendency.”

Thanks for the suggestion. (I tend not to give much credibility to posts heavy on accusations but light on corroboration.)

forumposter123@protonmail.com's avatar

Indeed, this is a well known and well documented issue worth untold billions and could be easily discovered with an absolute minimum cursory research. Its one of the biggest controversies in healthcare, and its the source of recent wild stock price swings in the industry (take UHC being down like 40% this year because the government is investigating their upcoding, amongst other CMS changes that might blunt their coding advantages).

Rich Helppie The Common Bridge's avatar

We covered what one buys when one buys Medicare (Dis)advantage. Subscribers get a gatekeeper as a way of reducing their care and choice.

Diane N's avatar

The "old farts" you are referring to were born at a time when the country was poor and the standard of living was much lower than it is now. It was their productivity that built the wealth. The government and all it's programs couldn't exist today if the profits from their productivity hadn't been increasingly extorted from them in the form of taxes and fees.

But the problem isn't the fault of the government or the old farts. Healthcare doesn't have to be an endless money pit. There is plenty of money to be made through the jobs created to construct the buildings, manufacture the equipment, staff the hospitals and other facilities, independent contractors to open gift shops and provide services for patient's families, etc. But then who deserves to profit from it all? The people who spend their most productive years actually working in it? Should they earn enough to have a comfortable middle to upper middle class lifestyle? Or should the profits go to a small group of shareholders/'stakeholders' (vultures?) whose only interest in it is sucking more and more money from it eventually causing it to implode?

The profit sucking stakeholder vultures are hoping that the people living in the middle to upper middle class segment of the population will answer that of course the profits should go to the stakeholder vultures and it seems to be going more smoothly than even they could imagine. By manipulating us to fight amongst ourselves, even pitting

generations against one other they have managed to suck increasing amounts of wealth out of the system, ruining the system in the process. Do you really want them to take your mom or dad's care away? Or grandma's? When they need it the most and spent their lives paying into it? Care doesn't have to be rationed, an infinite amount can be provided if the money can stay in the system to provide it. The only way they can fool us into thinking otherwise is by getting us to look around and start deciding who deserves care and who doesn't.

Everyone that is employed is required to pay medicare taxes at a rate that is decided by the government. There isn't a cheaper rate to choose for rationed care, nor is there a discount for allowing the hospital to profit by selling your organs and tissues. Now that these things are being implemented, people should be given those options otherwise those who have paid into it for 30 or 40 years expecting to get the care they need when they need it deserve to get just that.

Gunther Heinz's avatar

I used to work for UNIMED in Brazil as an economist. All you´re selling is just more BS, frankly.

Rich Helppie The Common Bridge's avatar

Nate Kaufman and I hit this false framing hard today. Based on our decades inside healthcare

https://thecommonbridge.substack.com/p/subsidies-shutdowns-and-the-healthcare

ANG Pilot's avatar

Wait...I'm supposed to feel sorry for and subsidize two people who voluntarily RETIRED EARLY?

Bill and Shelly aren't victims.

Democrats love to glorify dependent parasites. I'm sick of it.

Chris Bray's avatar

It's gross, but people respond to incentives. "If you do X, we'll give you Y." They took a deal that was offered to them. The bigger fools are the people who offered them that deal.

BornAlive's avatar

this fuckery is happening the solar arena too. i live in vegas. recently NV ENERGY decided those who have solar on their homes (the constant messaging is that solar is king and we should all get it! asap! like right now! yesterday!) must now pay an additional 70 bones a month to 'subsidize' the cost of those who do NOT have solar. in other words, anyone who spent the thousands of dollars to put that crap on top of their homes and enjoyed a few years of 19 dollars a month summer ac bills,now gotta eat it on behalf of us lackeys slow to put out the 20-50 grand for solar that needs to be replaced in less than 25 years...

Rich Helppie The Common Bridge's avatar

Chris - Nate Kaufman and I have been using our decades of experience inside the healthcare industry to expose the rotten design and also to present better policy.

We hit this false narrative about premium subsidies pretty hard today.

Feel free to link to it at The Common Bridge.

PS - You did a very nice job accurately portraying what the subsidies are all about. That stands in sharp contrast to most reporting.

PS - John Oliver may have lifted the content of an episode we called “Medicare Disadvantage” on The Common Bridge.

Captain Pompano's avatar

Agree it's not Bill and Shelley's fault. They played by the rules of the game as they were. But things change. And they'll have to adapt.

Lydia Lozano's avatar

It is their fault in so far as they allowed themselves to be used by the repulsive and dishonest Amy Klobuchar. So screw them.

JD Cleveland's avatar

I have friends and former business associates who made the decision to retire early ONLY because of the health insurance subsidies provided by Obamacare. I don't know the specifics about Bill and Shelly, but some of the folks I know are worth millions of $$ and can easily afford a monthly health insurance increase to $1700; they'll just have to take fewer European vacations and stretch out the leases on their Audi or BMW a year or two. It's a lifestyle choice.

gadflybytes's avatar

How do people worth millions of dollars qualify for subsidized healthcare premiums on the ACA marketplace?

James Nick's avatar

The subsidies are based on income, not wealth.

gadflybytes's avatar

That seems obviously structured to allow wealthy early retirees, like Bill and Shelly, to game this system, doesn't it? Klobuchar's tweet is about as out of touch as Nancy Pelosi showing off her SubZero refrigerator, full of gourmet ice cream in the middle of a lockdown, the one that just happened to kill a huge chunk of small to medium-sized businesses?

James Nick's avatar

The system is, it seems to me, designed to allow government to take over health care and force everyone into it. I think helping wealthy people game it is more of an unintended consequence. Typical outcome of central planning - a freight car full of left shoes.

Lydia Lozano's avatar

Allowing the government to take over healthcare was Obama's intent from the very start. The ACA is just the sharp tool he is using to accomplish his goal. Remember: "affordable care," like "affording housing," is affordable only because someone else is paying for it.

ScottyG's avatar

By reducing their taxable income, maybe in the form of tax free pensions. 🤷‍♂️

Orwell’s Rabbit's avatar

And by flat-out cheating, aided and abetted by lax enforcement by government/tax authorities. My spouse is an independent health insurance broker, and has encountered many types of egregious abuse of the system over the years…some so blatant that I couldn’t believe it.

We’re just finding out that millions of non-citizens are receiving SNAP benefits. WTF? As a legal immigrant (naturalized in 2008), immigration CLEARLY told me, during the visa process, that I could collect NO government benefits at all, and if I did, my sponsor would be financially responsible for repaying the government. How are people who are not eligible because of immigration status getting benefits to which they have no right? See my first sentence for the answer.

Cindy's avatar

Really the subsidized $442/month is pretty cheap for 2 people their age. My husband and I in our 50s and 60s pay $700 per month through his employer. And yes the amount a person pays is based on taxable income per your tax return.

And yes I do wonder that about the insurance companies, why not keep premiums high if they are going to be heavily subsidized. And my understanding is that the subsidies being currently discussed were due to COVID, so the increased amount they would pay would be as if Covid never happened, however these subsidies comparatively speaking are a drop in the bucket compared to Medicare/Medicaid.

I feel that the subsidies will prob be extended, maybe not in their entirety…

HeavyD's avatar

This is true. Subsidies are based on taxable income, not net worth. Depending on how your wealth is accumulated, especially given the current capital gains tax rules, a quite wealthy person ($5 million+ net worth) can qualify for subsidies. The system is so poorly designed, it is to laugh.

Kennedy's avatar

Exactly! Bill and Shelly can come out of "early" retirement and get a job if they can't afford it. As if we're supposed to feel sorry for these people who retired early. Unbelievable.

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Oct 31, 2025
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Rick Olivier's avatar

😂 a new one, love it

Gym+Fritz's avatar

I want to know more about Shelly and Bill, since I’m now supposed to care about their well-being, and help supplement their health care payments. How old are they; how long have they been retired? What’s their net worth? How much real estate do they own; where do they live? What kind of work did they do before they retired? What are they doing now, during their early retirement years? How much does their health insurance currently cost? Do they own a large boat?

Michael Woudenberg's avatar

That was my thought the entire time. Fuck Bill and Shelly who stopped working early and are upset that we aren't subsidizing it with people who keep working.

HamburgerToday's avatar

How do we know they 'retired early' because they wanted to? Anti-White policies affecting older Whites are everywhere.

James Nick's avatar

Although I agree with your point, I’ll note that, thanks to the government and the insurance companies, there aren’t many health insurance options available to early retirees besides the ACA. They could do COBRA as long as it holds out, but other than that, they’re pretty much stuck with the ACA. They could self-pay but that’s hugely expensive. As with everything else the government “fixes,” they degraded healthcare quality, made it more expensive and almost impossible to find alternatives.

Steenroid's avatar

That was my first thought. It’s their choice to retire early.

CherylBray's avatar

The entire ACA Obama care subsidy program needs to be abolished. It's financially unsustainable, is corporate welfare more than health care and will bankrupt the nation if not stopped.

Ryan Gardner's avatar

Yes.

Additionally, Obamacare was/ is used as a vehicle for State sponsored secularism. The whole point was to pit secularism against the nuclear family and religion.

Notyours's avatar

And Hoover up data about everyone through companies like “Epic”.

So they can ask about firearms, feelings, et al.

Tom from WNY's avatar

Lie, lie, lie.

None of your concern.

CherylBray's avatar

Can you expand on this? Or point me to more info on this aspect.

CherylBray's avatar

Ok. Definitely. Trans and abortion policies. Those are the overt ones.

I was wondering if you were alluding to the fact that allopathic medicine protocols in general (excluding acute care) are largely more harmful than beneficial. Vaccines, Antibiotic overuse, SSRIs, Statins, Chemo and it just goes on and on.

Most people don't take it that far. But I do. The entire medical cabal is set up to prioritize profits over health and without regard for the human cost.

Ryan Gardner's avatar

Yup. Another good point

AndyinBC's avatar

Along with all of the other sick, perverted "medical" procedures that WE are paying for!

Ryan Gardner's avatar

Ooh. Good point, Andy!

Hope alls well with you and the wifey!

AndyinBC's avatar

There are those that maintain the nation is already bankrupt.

Ike warned us not to jump down that rabbit hole - but we jumped anyway.

And we're getting awfully close to the inevitable crash landing.

CB's avatar

Another trillion in debt every 75 days, with the interval getting ever shorter?

AndyinBC's avatar

Yep.

That light in the tunnel is definitely a train.

And its accelerating!

Frontera Lupita's avatar

The ACA from the get go was one GIANT BOONDOGGLE!

James Nick's avatar

Yes, times a million! And to think, we were one vote away from killing it.

Tom from WNY's avatar

Obamacare was designed to be a wealth transfer program . It had nothing to do with Healthcare.

Any semblance to a medical support program was to ensure survival of Progressive Elites who did not want to engage in socially productive work.

Ryan Gardner's avatar

Exactly, Chris.

Its like the outrage about 40 mil people losing food stamps. Between that and the Obamacare boondogle you can see why they're good examples for why socialism is a failed and dangerous ideology.

If you are fed by the feds, you may want to consider the feds can also starve you. But that takes a lot of brain power to make that connection....

Mitch's avatar

maybe a couple months of providing for themselves is just what this country needs.

Ryan Gardner's avatar

Couldn't agree more. Bigotry of low expectations.

Wouldn't that be quite the experience.

Vermont Farm Wife's avatar

And after all this, just try to get a doctor to spend more than a few minutes with you, or to offer you something more helpful than another drug.

My husband had a bypass operation a few years ago and thereafter made an appointment with a cardiologist at a very well known regional "health care system". Hubby was told to make sure that all of his records were forwarded ahead of time, because this doctor always reviewed patient information before the visit.

The doctor spent much of the ten minute visit on his cell phone, glanced at my husband's records momentarily, then advised him to get a bypass operation. Which he'd already had. Which the doctor would have known if he'd bothered to look, even briefly, at the medical records beforehand.

We were not impressed.

AndyinBC's avatar

Hmmm. Sounds like we share cardiologists.

Unfortunately.

I just want to know how Hubby managed to get a whole ten minute appointment.

Frontera Lupita's avatar

The Modern Industrial Healthcare Delivery System is a total joke. It’s the Modern Industrial Sickcare Delivery System.

Shirlee's avatar

My doctor prescribed a medicine for me last week. I’m of Medicare age and it had a $675.00 co-pay. She said “yep, the government took the pandemic authorization off the med that costs $35.00 to produce.” The government has been subsidizing a business with our tax dollars. Needless to say, I didn’t feel $675.00 sick so the meds stayed at the pharmacy!

James Nick's avatar

Eliquis? $600+ for 30 days in the US, $45 in Mexico. Same drug, available at Mexican Costcos.

Frontera Lupita's avatar

That’s assuming you live in a border city with a Mexican Costco just across the border, or live in Mexico and are a member of Mexico Costco. But in general drugs in Mexico have always been cheaper than in the USA. And you can just walk into a pharmacy and buy them without a prescription. If you do have a US prescription, you can have a quick consult with a Mexican staff pharmacy doc and get what you want.

WA's avatar

Once again you hit the nail on the head.

I am one of those early retirees, except I live in California. I have extremely limited choices on the California exchange and I do not qualify for government subsidies nor do I want them for the very reason you point out!

ACA was, is and never will be affordable. It is a tool to push us all into single payer health insurance and oh what a nightmare that would be. Maybe this shutdown will expose the faults of ACA aka OBAMACARE! He and the democrats own it and it needs to be demolished. It only survives because of subsidies just like the EV market.

Oh just in case you are wondering what a healthy 63 year old female pays per month for subpar coverage a 60/40 Bronze PPO plan, 1,730 per month!

Affordable, nope!

Let’s shine a light on this broken, flawed, program designed to fail.

P.S. I do not hold President Trump accountable for this. It is all on Schumer and company.

Frontera Lupita's avatar

For that amount of monthly premium, you should go for ‘catastrophic coverage’ and just pay to belong to a concierge medicine practice. It likely would be cheaper. Many docs are creating these because they are done with the System and health care insurance in general.

WA's avatar

My thoughts as well but catastrophic insurance is a thing of the past. I will double check on that here in California.

Frontera Lupita's avatar

I was without health insurance for most of my adult life. I would have it for a year here to there when I worked at a jog that provided health insurance, but until I turned 65 and had to sign up for involuntary Medicare, didn’t I have it. And I hardly went to the doctor and for the infrequent times I went, I paid cash. I also found online lab services that did blood work, for very inexpensive rates. Far cheaper than a monthly health insurance premium. I used the services of holistic practitioners like acupuncturist, chiropractors, and massage therapy, and I treated myself with herbs and supplements, for ‘cold or flu like symptoms’.

There was such a thing as ‘catastrophic health insurance’ back in the day, but it appears from what you say it is now a thing of the past.

All the more reason to join a ‘concierge’ functional medicine practice, especially of you are under 65 and you feel you need to be under a ‘doctor’s constant care’. Insurance rates for people 50-65 years of age are astronomically high. That’s when people start to fall apart of they have not taken care of their health.

My philosophy is I stay away from the Industrial Medical Healthcare Delivery System as much as possible. I seek my healthcare needs with other practitioners first, before I would ever consider participating in that system.

PS: I just read your post again. You could see a functional medicine doctor, or naturopath regularly for under $1700 a month!! And certainly for less than $20,400 a year! 😳😱

Robert Curlin's avatar

Funny, I'm old enough to remember life before the much-touted "affordable care." At the time, health insurance for my other half & I was at about $500/month. For BOTH of us, and that was not cheap. But it was a great plan--$15 copays and a $500 deductible. Within 18 months of Oblahblahcare passing, the premiums for THAT particular plan increased to $1,930 PER MONTH. And that was way over 15 years ago. When we were promised "You can keep your Doctor. You can keep your current plan." What they didn't say was: IF you can afford it.

Then they tanked the economy again by bailing out the banks for backing gambling on Wall Street, to ensure it.

"Affordable health" (for us and most everyone I know who pays their own bills without gov't assistance) has been non-existent ever since. And the medical fraud has not only increased exponentially, but rages on--unchecked--and ALL of it is the insurance companies running fronts for massively cheating the government out of social contract dollars. They own the pharmacies, the medical practices, the hospitals...ALL OF IT. For this, you pay a "premium!"

Never forget the crux of "affordable care" was/is MANDATORY coverage. As in "it's illegal to not have (gov't approved) insurance." In other words, they can't continue the scam unless it's mandated. A government backed Ponzi scheme. And most folks are too lazy to learn how this works. Therein lies the mandatory jab--if anything is mandatory, somebody's laughing all the way to the bank. (And distributing profit sharing disguised as campaign contributions to keep their gravy train rolling.)

MacGuffin's avatar

Mr Andrew Mountbatten Windsor has demanded the delivery of Hunter Biden's old paintbrushes.

He wants to be called The Artist Formerly Known As Prince.

CB's avatar

Randy Andy was fired by Jimmy Savile's best bud, King Chuck (they sometimes wore matching kilts). According to rumor, Savile didn't just diddle boys and girls--he liked dying kids and corpses too, using his special access to "royal" hospitals. Talk about Halloween horror.

YourGalapagosGullfriend's avatar

The only thing more disgusting than Jimmy Saville's predilections was the cover up. Must be nice to be BFF's with royalty (Keir Starmer nods in agreement).

Susan's avatar

By the way, "KFF"? "KFF, a non-partisan health policy research group..." Isn't that the Kaiser Family Foundation? As in the massive, joined-at-the-hip-to-Dem-government Kaiser-Permanente? Not exactly a disinterested entity.

Leonard's avatar

Like every drug store that has a sign: Free Flu Shot (with most insurance plans).

So… its free as long as you already paid. Otherwise it isnt free.

CB's avatar

You always want to get your vaxxes from people pushing depopulation and other cost reduction programs.

Brian Nelson's avatar

Hey Bill and Shelly, I have an idea. GO BACK TO WORK!

Man, had to edit immediately.

Bill and Shelly--First of all--SUCK IT! Afterwards, go back to work.

bsn

AndyinBC's avatar

Shame on you BN.

This is an American 'stack.

You gotta speak 'murican.

No foreign words - like "work".

Very low probability Bill & Shelly will understand your post.

Brian Nelson's avatar

I imagine they understand ‘suck it’!!! Who would allow themselves to be profiled as such weak people? It is gross. They are gross. They were most likely at one of the ‘No Kings’ protests a couple of weeks ago as well.

bsn

Hey hey Paula's avatar

Nicely done. You took a fairly complex subject and distilled it into a simple understandable format. What concerns me the most is the absolute dead sound of options for how we get out of this mess. The people in the example are paying less a month for their health insurance than I am a retired individual. Where is my subsidy?

Chesterton's Fence's avatar

The fact that their last name is "Gall" is very appropriate

New Considerist's avatar

Right, as opposed to "Galt."

Rikard's avatar

"The submarine warfare..."

Excellent choice of imagery!

They run the same rackets over here too, of course, masking deductions and subsidies as something different from what it really is.

Depth charges away!