 I'm Betty Keller. I'm on the Health Care Committee's League on the Shoulders of Vermont, along with Kate Rader and Mary Alice, Vissy. And I'm also the president of the Vermont Chapter of Physicians National Health Program. So I have two different types of leaders today. And very glad to have you all here. We heard about the privatization of our 1111 Health Care Program in the United States. And some of the damage that is at risk for damage due to privatization. And we have two people who will be speaking with you tonight. Marvin Malik is a past president of the Vermont Chapter. He has spent most of his career in community medicine, providing care to underserved populations. After completing his training, he received a master's degree in health policy at Harvard University School of Public Health. From 2001 to 2015, Marvin served as medical director of the Berry Health Center, and later as a staff attending at the Inpatient Service of the Central Vermont Hospital. In July of 2016, after working on the novel of reservation at Harvard Months, he returned to Vermont to work at Springfield Hospital. To promote public understanding of health policy and public health, he hosted and co-produced a radio show, Public Health Radio, for many years. He remained active on the issue of health reform. He's frequently testified before the legislature to give him talks around the state, advocating for a more accessible and affordable health care system. He served on the advisory committee of the Green Mountain Fair Board since it was formed in 2011, until 2018. And he's been a member of the Physician's Financial program since it was founded in 1987. So thank you very much. And I will introduce Tom Abdelmauer. I mispronounce it myself sometimes. After we heard from Marvin. So thank you so much all of you for being here tonight. Thank you. Studies recommend that I take this off because there may be people in the audience who use lip reading to help them understand things. So I'll hope we don't catch COVID tonight. I just want to say that Green Mountain Care Board did not necessarily listen to the advice that those of us on the advisory board gave them. To those of you who've been on it, you're aware of that. So tonight's program is on the Medicare program. And to fully understand what the recent changes in the Medicare program, I think it's useful to go back and look at the past origins of the Medicare program and then follow its development. So during the 1960s, early in the 1960s, 1962, Michael Harrington came out with a book, The Other America. Many of you, it's a very well-known book. Many of you may have read it. And talking about The Other America, not pictured in the 1950s situation comedies, people who were quite poor. And among the issues related to poverty and lack of affluence was the situation for the elderly, half of whom had no insurance for hospitalization. And many of them, a quarter of them went without care due to unaffordability. So there was a movement. So in the 1960s, there were many social movements going on. The ones that we remember most best because of their importance to American history are the civil rights movement and the anti-war movement. And the environmental movement and the women's movement got going too back then. But there was another movement, and that was the fight for health care, especially for the elderly and the poor, who were really left out of the current system. As you may know, health insurance in the United States began with private health insurance provided by employers. This occurred as a result of the very strong union movement this country had from the 30s to the 50s. And unions were, as a benefit, they were asking for health coverage for the workers and their families. And by the end of the, by around 1960, about half of the workers in the United States had some sort of employer-based health insurance. So provided by, again, private health insurance companies. So as a result of social movements, we ended up with, yeah, let me just go through this. The Great Society legislation. And here you see Lyndon Johnson with Harry Truman sitting next to him, signing the Medicare legislation into law. And I think they made Harry Truman the first beneficiary. Anyway, so that was a success. And now to understand it better. So social movements can succeed. And this one did after people were out on the streets. So there's the card. And without any computers, because there weren't any then, they got everybody, virtually 99% of eligible people enrolled within six months. Through the mail. There's Harry Truman's signature on there, by the way. I can't get rid of this slide. OK, so in traditional Medicare, which is what was signed into law, it's quite simple. The Medicare program pays the doctors when they provide you medical care, whether it's in the hospital or at the doctor's office. And that's the model to this day in what we still call traditional Medicare. However, from my point of view, the biggest problem with Medicare is that the benefit is inadequate. And it was inadequate right from the start. And it has improved relatively little over time, with the exception of the prescription drug program. So what this slide is showing you is that up to 400% of poverty, which for a family of four would be $100,000 a year, most people are spending more than 20% of their income on medical care, which is a huge strain on people to have to do that. So that's with Medicare. If all you have is Medicare, no supplemental coverage, and no other plan to help you along. So and this has always been the case. Traditional Medicare exposes people to bankruptcy. The most important part of that is this, the 20% outpatient co-insurance. Now outpatient, just to define what that means within the Medicare program, that's every doctor visit. Many hospital staves that are categorized as observation, shorter hospital staves go into that category. And if you're of cancer and you're getting a chemotherapy infusion, that's in the category. If you get a CAT scan of some part of your body, that's in the category, all the lab tests. So this is actually, this is now a larger amount of money than the hospital part of the program. And it's referred to as Part B of Medicare. And that has a 20% copay all the way. If you have no additional coverage. This is a, and I mean all the way. There is no annual cap on how much spending you could do. So if you're getting outpatient infusions for cancer medications, you're really going to spend a whole lot of money. And very likely go bankrupt. So that by itself is, that's really the main problem. There's also, this year, the deductible is now $1,600 if you're hospitalized through the Part A part of Medicare. So there's big copayments both in Part A and in Part B. And as I said, there's no limit on spending. So if you have a lot of money, you have a choice. That's how it is here in the United States. You could do nothing in risk bankruptcy. Option two, you could purchase a Medicare supplemental plan. And obviously, you would want to do that to give yourself protection. Currently, for this year, my premiums that I have, I'm in this category, this is what I'm choosing. Because now we have this other choice, which is the big focus of tonight, the Medicare Advantage Program. $2,000 a year is what I spend. And that's what most people spend. It's $165 a month. If you do the math, it's $2,000 a year. And that's before I pay for the Part D drug plan. Yes? Medicare does provide assistance in terms of reducing the outrageous charges that hospitals make. In other words, when I look at my bill, I see $1,500 for some service. Medicare pays $200, and the hospital accepts that. Right. So you can't just look at the cost of a hospital versus 20% of that. You're a lower amount there. What bills look like in the United States is really complicated. But all insurers, including Medicare, generally try to pay less. And Medicare can pay less. Larger private insurance companies pay less. You have heard many sort of free market-oriented people say that we should allow us to buy policies from other states that wouldn't have to go through our insurance regulator in Vermont. And if a doctor were to submit a bill to them and they tried not to pay at all, the doctor would not accept that. So the insurers within Vermont, including Medicare and Blue Cross, they pay less. In general, the private insurers tend to end up paying a larger amount. Anyway, so these are your options. And it would be very rational if you have the $2,000 a year to get yourself a supplemental plan. I just want to say that the most important change, in my opinion, in the Medicare program does not even have to do with the Medicare advantage situation, which we'll talk about more. But it's to improve that benefit. Because if we had a benefit where your maximum amount of money of out-of-pocket spending was either $0 or $100 a year and not thousands and thousands of dollars, then the rest of today's discussion would be moot. And we would have decent health care. Everyone. OK. Now, in 1982, there's the first example of subcontracting to a private plan. The Center for Medicare Medicaid Services initiated a pilot program where they would pay a fixed monthly payment to a private plan. So the Medicare money from Washington is going to a private insurance company. And that insurance company becomes responsible for funding all the medically necessary care included in the Medicare benefit, which is a lot. It's all this hospital care, Part B, all the doctor care, cancer care, x-rays, all that. So they were subcontracting to a private plan. So my question to this audience, now a lot of you are more than about 55 years old. And if you're more than 55 years old, you have the opportunity to remember 1982. Now, in 1982, does anybody remember a social movement where people were out on the streets like they had been in 1960, the people fighting for Medicare? Does anyone remember people out on the streets saying, you know, we really want Cigna and Aetna to pay the Medicare benefit. We want them to get the money and then pay my doctor. I don't like the fact that Medicare is paying my doctor directly. I really need one of these private insurance companies. And I'm out on the street picketing. And I've got signs. Does anybody remember those demonstrations? No, they didn't happen. So what happened in 1982 that did make that happen if it wasn't social movements and public pressure? And here's the history. Private insurance, in 1965, were happy to let the government pay for care for the two most expensive groups of people, the poor and the elderly. And they could keep taking care of people who were able to work, who were the healthiest people in society, and their families who tended to be healthy too. So it's like, we'll take all the people who aren't going to cost us very much. In government, you can take all those people who are hospitalized all the time who get things like heart failure and lupus and cancer, you know, that you can just handle them. However, between 1965 and 1985 and continuing to this day, there was a stagnation and growth of the private insurance industry. Their product was too expensive for many small employers, like a gas station owner or a restaurant owner. They couldn't afford it to provide that benefit for their employees. So we only reached about half of the working population getting insurance through their job. And so that market was stagnant. We call it a market in the United States. They don't use that term in other countries. Anyway, the number of people they were providing insurance for, their revenue stream was starting to be pretty limited because they weren't able to sell to many more workers than they already had by around 1965. So in the 1980s, the private insurance companies together, they have a lobby, you know, a trade group lobby. It's called AHIP now. Had a different name then. Anyway, they got together and they said, well, let's take another look at the poor and the elderly. Maybe there's a way that we can come up with a business model that we can make money in that market of the elderly and the poor. And they developed a strategy which we're going to go through tonight. And the reason why this is such an appealing market is this individual here, supposed to be Uncle Sam, he's got really deep pockets. He can just keep paying. Whereas a gas station owner doesn't have the deep pockets that Uncle Sam has. So there was potentially a lot of money that they could receive if they started ensuring the federal programs. And this is the era when, this is Ronald Reagan's first inaugural address, which he gave in 1981, a year earlier. Government is not the solution to our problems. Government is the problem. But try to tell that to people who got Medicare in 1965 that government was a big problem, because they would not have said that. So this is the era of the 1980s, the era of grow private greed. Greed is good. Anybody get my slides to go ahead? So this is the origins of the original Medicare Advantage program. It's changed names. But basically, regulations were developed, and the program was officially launched in 1985. Medicare Part C, it was called. And then changed its name to Medicare Plus Choice in 97. And growth was very gradual through 2000. This was actually a period. Remember you remember the 90s? This was when the term managed care became an expletive. It was not looked upon very fully. Whole movies were made about where managed care, where people were cheering at the movie when the insurance company was made to pay. Anyway, so payment to participating insurers in the original program for 20 years was 95% of the average cost of a Medicare beneficiary. And they began doing age adjustment in 1997. But either way, they were getting 95% of what the average Medicare beneficiary was costing the Medicare program. So it sounds like this is a real bargain for the taxpayers. Instead of paying 100%, they were going to pay 95% only. So there would be a 5% gain for the Uncle Sam, the Medicare program. Does anybody know what actually happened? Didn't work that way. The reason why was because very, very quickly, the insurance companies figured out how to market their product to healthy people. They never, ever advertised in a nursing home. They were advertising in retirement communities where people had to have lots and lots of money even to get in. So this is called the terminology is selective marketing. They figured out who they wanted to insure and they marketed to that community and succeeded. So right from the start, from very, very quickly on the Medicare program was, I'm sorry, the Medicare plus choice program was a burden on the Medicare trust fund. It was depleting the treasury, in other words. The private insurance company's business model was working. So that gets us to the end of that century. And this is just to understand the model. Instead of government paying the doctors directly, there's this in the middle, managing everything. So then in 2003, the Medicare Modernization Act passed and Medicare plus choice was renamed Medicare Advantage at that time and that name is held to this day. And because that 95% thing was so widely abused and Medicare had spent a huge amount of money trying to prevent selective marketing and to prevent the insurance companies and to find them if they were doing selective marketing and picking off healthy people to insure. Finally, they gave up on the 95% thing and they created a more complex system that the way they were going to pay the private insurers. They weren't going to get rid of the Medicare Advantage program because it was losing so much money for the taxpayers. That was asking too much. But so what they did instead was they created a risk-based coding system. So somebody with heart failure would get them more money than somebody who didn't have heart failure, that they would come up with an adjustment, a billing adjustment, to say, well, this patient is 85 and has heart failure, so you're going to get X amount of money rather than a lower amount of money that a healthy 66-year-old would get this insurance company. So that looks like it would solve the problem. We'll get to what actually happened. It's a little more complicated. And what happened is vendors began marketing software because now we have computers and software and all that. And the insurance companies who were offering these Medicare Advantage plans started spending money on creating software to game the system. You no longer had heart failure. Now you had systolic heart failure with depressed LV systolic function, ejection fraction less than 40%. You now had more coding done that was gaming the codes that Medicare had created in the system. So the effort to change the 95% thing, which was so easily abused by the insurance companies, it didn't work. The insurance companies were quite able to game the system. And I'm going to show you a little more about that in a second. And in fact, very quickly, the plans were being overpaid. And the coding thing is part of it, but there was some legislative overpayment where instead of paying them 95%, they were now starting out at 100%, even for a health, I'm sorry, 107%, even for a healthy person. And then if they have heart failure or cancer or something, then it goes even higher. So what I'm getting at is that the federal government essentially began intentionally overpaying Medicare Advantage plans. And at the same time, allowing them to take this extra money, and this was the intent of many legislators, to allow them to be overpaid and expect that they would provide extra benefits, hearing aids. Now, earlier I said that what I believe should happen is we should bolster traditional Medicare so that it has those benefits and people don't need to get into a private plan to get hearing aids or glasses or something other than a 20% copay for all a part B Medicare that we need to improve their benefit. But this is what happened instead. Government, the Congress of the United States and the president at the time, George W. Bush, they were going to give extra benefits to people only if they signed on to a Medicare Advantage program. So here are some of the benefits. So almost all the plans provided dental care, hearing aids, fitness center, memberships, or subsidies to get them, and eyeglasses. And then if you look further, transportation to appointments and meals could go either way. OTCs would be like Tylenol over the counter drugs. And then there's these other benefits that they were authorized to provide. Caregiver support for people who had a caregiver at home who was completely exhausted because the patient has Alzheimer's and they're just a handful to take care of. So very few of them offered that. Tele-monitoring for people with advanced heart disease. Bathroom safety and in-home support. So if you think about those benefits, why do you suppose the insurance companies went along with these benefits and not caregiver support and bathroom safety? They're at home because they're sick. So anybody who needs, anybody who has tele-monitoring, probably has advanced heart disease. Somebody who needs, whose bathroom safety has got some significant neurologic problem or they're just very weak. What I'm getting at is that the benefits they don't provide are for people who are going to be expensive. And the benefits they do provide, who wants it? Does somebody who is totally stroked out and can't move, do they need a fitness center membership? Probably not. A lot of healthy people need glasses and maybe hearing aids. So that one, these were benefits that were commonly provided. So you're getting a sense of the strategy, the business model for the Medicare Advantage insurance companies. One of the selling points was also nursing homes. I didn't see nursing homes up there. Nursing home care is provided in a different way. And we're going to talk about that later in one of my, I have a few cases if we have time. So because of these extra benefits and because the US House of Representatives and the Senate and the President together, we're making Medicare Advantage plans more and more appealing by providing all these extra benefits. And the one I didn't mention was reducing the premiums to get into the program. So now you hear Joe Naim is coming on television. What's your zip code? We'll figure out if we can, how far we can reduce your premiums because the way it worked in the Medicare, the way it works in the Medicare Advantage system is that each zip code has a certain amount of expected medical costs. The cheapest one in the country is in the middle of Nebraska, most expensive one I was surprised to find out is Staten Island, New York City. So for Staten Island, the Medicare Advantage plans, if you live in Staten Island, the Medicare Advantage plans get over $7,000 if you're absolutely healthy. Whereas in Nebraska, they only get $2,800 if you're absolutely healthy and 65 years old. So they do it by zip code, and in most zip codes, however, you're going to end up with cheaper premiums, with spending much less on premiums than if you tried to buy a Medicare supplement plan, which is now $2,000 a year. You're going to spend a lot less than that to get into a Medicare Advantage plan. And that's because, basically, of overpayments. So what you're seeing here is since 2010, and this is actually since 1965, almost. Yes, overpayment by the federal government to the private insurance companies that are offering Medicare Advantage plans. That's why they should do it for picking up enormous bills. They're being overpaid, exactly. So this slide shows you that the growth of private health insurance for mostly employed younger people, under 65, has been very stagnant. But revenue growth for United Health Care, which is the largest insurance company in the United States, more and more money coming from the Medicare program. This is the overpayments and the enticements that have prompted more and more people to sign up. Turns out that's also true for the Medicaid program. It's almost identical strategies. Although in the Medicaid program, one of the biggest strategies is the network strategy, is that in a poor community, typically, the closest hospital will not be part of the plan. They have to go to some other hospital. It's really, that history is really sorted, but that's not the topic tonight. So Medicare middlemen generate their profits by the same three methods as any other business. And somehow, I was so fancy in making the slide. There we go. Increase the number of people in the program, number of units. Maximize the revenue for each patient that you enroll, and then minimize your expenses. So we'll go through this. So increase the number of people and here's Joe Namath and J.J. Johnson, I guess, hawking Medicare Advantage plans. By the way, they are not representing Medicare Advantage plans. Both of them, if you call these numbers, the Medicare Helpline or whatever it is, they're insurance brokers. And the insurance brokers in most states get an average of $500 if they get you on to a Medicare Advantage plan, and half of that every year that you remain in that plan. So this is your tax money being diverted to an overpayment to the Medicare Advantage plan, part of which is diverted to an insurance broker. This is how your tax money is being used. And so they pay about $500 if you sign up for a Medicare Advantage plan, but only about half of that if you sign up. If they tell you about a supplement plan, the $2,000 a year to have actually total covered, they get only about $200 or $250. So these insurance brokers are very biased. They want you to sign up for a Medicare Advantage plan because they're gonna get more than twice as much money if that's what you choose. How much they mention co-pays, narrow networks, prior authorization, denial payment, you're less likely to hear about that. AARP is receiving a massive kickback from UnitedHealthcare to allow their name to be on the UnitedHealthcare Medicare Advantage plan. And speaking as a doctor who works in a hospital, it's like Dr. Jekyll and Mr. Hyde, there's no AARP in the hospital. There's UnitedHealthcare behaving like UnitedHealthcare behaves, which we will get to. But AARP's not there in the hospital telling him, oh, this is a needy senior citizen, please pay for their care. No, that's not what's happening. So maximize revenues per patient is another strategy. And they lobby for high benchmark payments. And it turns out that there's some quality measurements within that the Medicare, the governmental Medicare bureaucracy and Center for Medicare Services, they're measuring some quality data. And this affects that amount of money that you get in if you're a Medicare Advantage provider and that zip code, whatever zip code you're in, they get a little more money if they can convince the federal government that they're providing high quality care. Of course they're not providing the care the doctors are, but you know, go figure. Anyway, but there's been a lot of distortions and outright fraud in those quality audits. And when the government comes in and re-audits them, they're much more likely to be overstating the quality of care rather than understating it. So that's been an issue. Another one is hospice care for Medicare enrollees is paid for by traditional Medicare. To me, this is absolutely outrageous. Like, if you sign up for a Medicare Advantage plan when you're healthy at age 65, let's say you make it 12 years and you've been healthy. So they're getting all that money, we'll talk about how much in a minute, what it ends up being. And then finally, maybe you get cancer and you're gonna end up in hospice a year later. So they've been getting all that money for all these years, finally you're sick and that's when you need your insurance. But if you decide, you know, if you elect finally hospice care, because you need hospice care and the cancer's not going very well, suddenly they don't have to pay it. It's coming out of the Medicare program. Uncle Sam getting ripped off again. And I just, I'm sorry, I just find this really outrageous. So the average person who enrolls in hospice has 87 days total in hospice. That's the average. And if you do the math on that at $200 a day, it ends up to $17,400 per person. It's coming from the taxpayers. All right, and then the third, we've already talked about up coding and gaming the risk score system, which gets the plans higher payments from Medicare, regardless of how much care the patients actually receive. So here we go. And now you're gonna hear what these, how much money they're actually getting. So this is a healthy person with 76 year old female. She's healthy. And so the risk score turns out to be 0.45 if you're healthy, that's just what they chose. And in an average zip code, that would get the average Medicare Advantage plan $4,000 annually. This is a couple years old, so it's probably a little more than that now. But here's another person who is somewhat overweight or even obese, type two diabetes, which for many people is, we can talk about this later, but it's really easy to diagnose type two diabetes and over call it. For those of you who have type two diabetes, and it's not so severe, a lot of times your hemoglobin A1C will dip below 6.5 and then technically you don't have diabetes. So if you've had four measurements in a year and one of them is above 6.5, suddenly you're diabetic and the company gets more money. This is the deal, this is what goes on for a borderline diabetic. Major depression gets them no bonus, heart failure gets them 0.323, asthma, nothing extra, and ulcer, and then there's an interaction code if you have both heart failure and diabetes, you're more complex to take care of, so they give a little extra money. So this would get the Medicare Advantage plan, $9,000, because you have a bunch of problems, but they have really good software. So that software is not gonna let those codes go through as you're seeing them. What's gonna happen is they're gonna see this. It's morbid obesity. And they actually have some eye disease from their diabetes, so now they get 0.318 at upward adjustment rather than 0.104, and now their depression is single episode and mild, and don't ask me why that code's higher than major depression, I can't explain that one, but the software knows that, so that gets them some extra money, and then now they have class three heart failure. This didn't get them extra money, but they put it in anyway. COPD rather than asthma, in many cases, the two kind of overlap, and it's not so easy to tell them apart, so if one in doubt, more money. And then you can stage the ulcer, and that got them a lot more money, and then you've added COPD to the mix, so there's a higher interaction code. So the software recoded the patient, and now the payment went from 9,000, very same patient, to $32,000 a year, going from the Medicare trust fund to this Medicare Advantage plan. So this purchasing software to help them code is worth it. Nonetheless, it's taking our tax money, going through a Medicare Advantage plan, not to give you medical care, but to allow software companies to make a profit. This is how the Medicare Advantage tax money is being used. So you're saying that's not true, essentially? Yeah, well, I like that word. They're exaggerating. Or do you think that's criminal behavior? And sometimes, well, and sometimes it's just being more descriptive. You're just saying more about the patient, in a manner that'll, I'm sorry, in a manner that'll get you more money. So it may be, this may be entirely accurate, but the computer figured out a way to not submit it in that form, but instead to submit it in that form, yeah. The run of state colleges and all that went to, for their retirees, made us all sign up for a sign of Medicare Advantage plan. Shortly after that happen, I received a questionnaire to ask me to list every single precondition I had ever had. Oh, it happened, birth. Absolutely. Another one of their strategies, by the way, is to send a nurse to your home. And a lot of patients, when they hear there's a nurse coming, they think that's wonderful. This nurse is coming to help me. Those visits are entirely to find more codes. Yeah, so, for sure. So it's an incessant search for more codes, home care visits, wellness exams, help them with that. And they data mine the electronic health records to find more diagnoses. And then the software we already talked about. And then direct financial incentives to primary care doctors to do more coding. This is for real. Yeah. Pitches, why is it this? The cost of living and the average cost of medical that's spent on medical care is higher in Staten Island compared to the- Is there a hospital in Staten Island? Well, they may be going to hospitals on Manhattan. The residents of Staten Island have high medical costs. That's what they're saying. It's not a character fluff. People in Staten Island are very nice. But they are now discovering this and they're quite disturbed about it. Oh, that their Medicare Advantage plans are being paid so much? It's the U.S. Okay, so the overpayments followed over time. The average overpayment is in billions. Those dollar amounts are in billions. So it's been extremely high. So if you average this per person, every time somebody goes from traditional Medicare and instead elects a Medicare Advantage plan, the taxpayers lose $310 per person. And if you add all that up, it's $16 billion in the last year. Oh, I'm sorry, forgive me, in 2021. So what do they do with their overpayments? And we've already talked about this. They improve benefits, lower premiums, add dental vision, audiology. They could add those other benefits like home care, but that's not what they do. Again, lower the premiums. Spend money on up-coding software. Spend money on advertising, money to insurance brokers, and increased dividends to investors. This is about a third of the overpayments go to their investors. So it's a very profitable industry, which we've already talked about. And they minimize revenue spent on healthcare. Before there were Medicare Advantage plans, traditional Medicare was very efficient, only had 2% overhead. The Medicare Advantage system, much, much higher. So only 85% of every tax dollar is actually going into getting patient medical care. Yeah? Teach them how to add these extra colors. Of course. Right. They teach them how to do that, and then the minute that somebody gets really sick, they take them off Medicare Advantage and say, you have to go back to regular Medicare. And they can't even get co-pays at that point. So that's not the thing. Many people end up... Remember that playing field, health center will not accept Medicare Advantage. I thought that was wonderful. So the third main strategy, the third of the three main strategies, to minimize medical expenditures. Okay. So once you've gotten all these people to sign off, and you're getting a maximum amount of money per person with the up-coding and quality distortions, whatever, you're getting more people and more money per person. The third strategy is to say, okay, so we've got all this money, now let's keep it. So how do we avoid spending it? So just in April of last year, finally the Office of the Inspector General of the federal government did an audit, and they find out in their understated ways, some Medicare Advantage organizations denials of prior authorization requests, raised concerns about beneficiary access to medically necessary care. Not a catchy name, it's not like Gidget or the name of some movie. This is sort of complicated. Anyway, so what the audit showed was that it wasn't just prior authorization, was that 13% of prior authorization requests which were denied were completely valid. What they don't say here in the title is that 18% of total denials were, and this affects me and the inpatient side, we take care of a patient in the hospital, and at the end of the day we get zero. That patient did not need to be in the hospital. I'm not joking, this is happening all the time. Mainly we have mainly United Health Care and Well Care doing that, and this is all the time, denying, attempting to deny it. We call it the spaghetti test where they take spaghetti, throw it against the wall and see if their rationale for the denial is makes any, can stick, and they can not get prosecuted as a consequence of it. So denial of payment, even for an entire hospitalization, this is something that is happening. It's not an occasional event, and they did a poll of Medicare beneficiaries and they found that a third of them have had care denied. Now prior authorization is different from denial. That's where you deny it before it even happens. Whereas our denials, all of my admissions to the inpatient service are through the emergency department. There are people who came to the hospital because they were sick, and we found that, yes, they are sick and sick enough to require hospital care. Whether it's kidney failure or heart failure, whatever it is, or they're just having terrible, terrible side effects from chemotherapy and they're totally dehydrated and their electrolytes are way out of bounds. So that's the kind of stuff we're treating, and it's all through the emergency department, and then the Medicare Advantage company will say that could have been dealt with at home. The patient could have somehow taken this horrible frightening potassium level and dealt with it at home. Go figure. Prior authorization is the plague of primary care. Let's say your back is unbelievably painful and then the pain's going down your leg, all the way to your foot or something like that, and your doctor's trying to order an appropriate imaging study for that, whether it's a CT or MR study, and that gets glommed into a system that the private insurance company imposes on doctors called prior authorization, where the patient will not have the x-ray funded by the insurance company until they approve it. You can get the CAT scan done. It's just that you're risking that the insurance company will decide that it wasn't necessary. And if you do get it done and without their approval and it's actually positive, then they'll pay for it. But if the study is negative, then they'll say, well, obviously we were right. It wasn't necessary. So the doctor thought the test was useful, but they have people sitting there in a cubby in a suburb of Dallas, sitting there deciding who've never seen a patient, who've never seen your patient, because they're in Dallas, and they're telling you that this procedure's unnecessary. That's what it does. And you can tell that when this is happening, when I'm behind in my schedule and primary care, my blood pressure rises. But I'm not the main victim of all this, so you can imagine who it is, namely the patients who are not getting the care they need. So this is a lot of people, and I can, we're probably not gonna have time, but I can tell you about a case that was considered a justifiable denial. And I can see why, but think about this case and we'll get to it later if we have time. So, oh, I gotta hit this thing. So, back to this, you saw this slide before when the program began. But now, the rule hasn't changed. CMS makes a fixed monthly payment to a private plan, which becomes responsible to fund all medically necessary care. I didn't emphasize that when we had the slide before. So who do you think is deciding what's medically necessary? It's not your doctor. So that's how they get away with it. They're the arbiters of medical necessity, and this is how they get away from... So what you're finding is for people in Medicare Advantage Plans, they're less likely to go to the top-rated cancer hospitals. And I just wanna make a comment on that. This, compared to people in traditional Medicare, so if you have a Medicare Advantage Plan, you're not gonna go to Mass General for cancer surgery. Now, many people who have cancer don't need to go to Mass General, but many, many patients with cancer have, there are features of their cancer that are unique and may make surgery technically difficult, and they do need to go to Mass General. And with that person sitting in the cubby in Dallas, deciding what's medically necessary, this is the result where people end up not going to get the care they actually need. So the net result of all this is that when people actually get sick, so these are the people who are not very sick, and what's going on here is that people can go back and forth from traditional Medicare to a Medicare Advantage Plan, and then back and then back again, so they can go back and forth. But who actually is going back and forth? And what you can see, for the relatively healthy people, there's flow in both directions. But people who've had a short-term nursing home stay are a sicker population, they're a whole lot likely to go from a Medicare Advantage Plan into traditional Medicare compared to a flow in the other direction. And if they had a long-term nursing home stay, then they're really likely to wanna leave the Medicare Advantage Plan. And that's what's going on here. The sicker people are more complex, they're not staying in Medicare Advantage Plans. And one of the points here is that even though you're sick and they can code you higher, you're still not worth it to them. They want you to leave, and that's what you need to understand. This is part of the insurance company's model. They don't want the revenue for somebody who's that sick. They want you to go back to traditional Medicare. And when Mary Alice made her statement, it's not that they force you to go back, it's that you kinda want to because you're left with all these costs. So of all the people who leave Medicare Advantage Plans, over a quarter of them say that the reason was that they couldn't get the care they needed. And the providers they wanted to go to were not in the network. So traditional Medicare with a supplemental plan, if you have that, which I'm paying $2,000 a year for, as I said, you can receive care at any primary care provider's office, or a specialist office or the hospital, no permission needed, there's no prior authorization, there's no person in a cubicle in Dallas who's making your life-authoring decisions about your health, no out-of-pocket expense at all, and no surprise bills. And the patient can trust that it will be there for her. Stability and high quality coverage, which is what the healthcare system and most every other country provides. And we're not there yet, here in the US. But if she has the $2,000 a year, she'll be cared for and she'll be stable. It's $2,000, as I said. By contrast, Medicare Advantage System is complex and inefficient. Complicated, but it has lower premiums and more of these side benefits, glasses, dental care. So that's the plus, and that's why people are signing themselves into it. Also, they may not know the disadvantages. They're not well-publicized, as you know. So it's complex, and it adds to the administrative costs the doctor faces, too. So this adds cost to the whole healthcare system. The doctor has to spend more money on the billing systems to contend with all this. We're heading profits, avoid taking care of sicker people via all the strategies they have, mostly very limited networks and prior authorization. Turns traditional Medicare into a high-risk pool where the expensive people end up there, they possibly can. By managed care tools, what they're talking about are denial of care, prior authorization, those are the tools we talked about. And narrow networks. So that's what you're facing. So any questions now? I'm gonna talk about one little more recent development. Yes, in the back. This seems to part back to the worst days of HMOs. And HMOs became extremely unpopular. I found out through personal experience that because I discovered I had a genetically-caused aortic aneurysm, that aortic replacement at mass general with complication rate is less than 1%. At Dartmouth-Hitchcock, which is a very good hospital, and I mean it, no disrespect, the mortality rate is 5% and the complication rate is 4%. They say that on their website. But I have no doubt whatsoever that if I had a met advantage plan, I would have been required to go to Dartmouth-Hitchcock rather than to mass general. That is the, that's what goes on. And I've known lots, I've known a number of people who have been told by UVMC or Dartmouth-Hitchcock that they've done all they can for them. And I've gone down to Boston or gone down to New York and discovered that there's more that can be done. I mean, these are rare cases, but it's the kind of freedom of choice that I think most people would like to have for themselves and their loved ones. Yeah. Yes. I want to take two more questions, because we feel a little bit... From the federal government to push so many people into Medicare events, I mean originally I thought maybe it was financial, but you know what you're telling us, these guys are ripping off the government by exaggerating the quality. And then they're skimming by taking off the plastic patients and giving the sick ones back. So I'm wondering if the push is more ideological that certain people since Lyndon Johnson got this thing's past have hated this and want to privatize it. And it's about privatization, but it's also about ideology. What do you think, what is the real push from an economic point of view that the federal government is spending more, it looks like, than left with it in the long run? Okay, so you've raised the possibility that the reason for this are ideological. And I'm going to respond to that in about five or 10 minutes when I get to a few more slides. But everybody hold that thought in their head, okay? It's an important point. Take one more question, yes. I've noticed that UVM has been advertising they call UVM health advantage procedures. Is that just a wolf in different sheets globally? Is that still a Medicare Advantage program, but they're just calling UVM health advantage procedures? It's a Medicare Advantage program. That's what I thought, but they're not calling it that name. Well, I mean, I don't think they're hiding it. It's a Medicare Advantage plan. And to me, and I think the problem is, as somebody who provides medical care to people, especially at a small rural hospital, it's often difficult for us to balance a budget, especially after the pandemic for all that's meant for. And even UVM had a negative, they had a loss this year in their medical care. So if they're powerful enough in the healthcare system to start a Medicare Advantage plan, which where they know they're gonna get overpaid, I don't think you can criticize them. It's the problem is the system that allows insurers to get overpaid while Springfield Hospital does bankrupt, trying desperately to provide care for a very poor population. This is emblematic of a dysfunctional healthcare system. I understand that they're not calling, I guess it's the wording. It sounds better to call it a UVM health advantage because if they've got that Medicare Advantage plan. It's a Medicare Advantage plan. Right, but then I guess my point is they don't want to say that. Yeah, you know. It sounds better. Okay, one more question. Well, the question has to do with this thing about Staten Island, because Staten Island is not a rich place. Most of the people living on Staten Island are not well-to-do. So that the section of people who are well-to-do, excuse me, this is the problem. The section of people who are well-to-do are paying their health insurance payments about up and up and up. As in the case, this is the person I know. And most of the people on Staten Island have no insurance with the average. And then when they get sick, they get on the boat and go to the emergency room in Manhattan and end up with bills or whatever or things that they can't pay. They incur high medical costs. That's why they're being paid more. It's not that they're wealthy. Is it what? They are incurring their generating high medical costs. The people who live on Staten Island, that's where the adjustment came from. It's not that they're rich. It's that the care they're getting for whatever reason seems to be expensive. Care provided in Manhattan may have higher prices. You know, who knows all the reasons? As an aggregate, there are well-to-do people on Staten Island who are paying for health insurance and probably get doing better in terms of the deal that they're getting because they are the minority of people on the island. I get it. Let's just move on because I won't be able to finish because I don't have all the answers about Staten Island. I've only been there once because I wanted to see the Statue of Liberty from the Staten Island Fair with Fair, which I strongly recommend. OK, so Medicare Advantage continues to grow. This is the yellow. Each year from 2014 to 2022, they're growing. And the percentage of people left in traditional Medicare is dropping. And within a few years, they're going to be equalized. So Medicare Advantage will be so appealing to so many people that it'll be half of the people in Medicare. So the private insurance companies are making money in the Medicare Advantage system, as we pointed out. But they're not really making very much money with these Medicare supplemental plans. So they've been rethinking that group too. For those of you who hope that this part of the story wouldn't happen, this part of the story is happening. So just watch. This fellow was a former roommate of Jared Kushner. And in 2019 was the head of a little think tank that generates ideas for the Medicare program and where it's going to go. So President Trump, at the time, appointed this fellow, obviously very young, and he has no experience as a health patient care, believe me, appointed him to be the head of this think tank, the Center for Medicare Innovation. And he had begun a startup company called Landmark Health. And he created a program that Landmark Health was going to participate in, which was going to make a whole lot of money. So he took traditional Medicare. And within that program, he found a way to insert private corporations into the benefit, which would happen to people who chose not to go into a Medicare Advantage plan. They were going to get Landmark Health. And he then left. And a year later, a friend of his took over, another experienced fellow who spent years at the bedside, you can imagine. And he officially started this program. He later worked for Anthem, which also got into this bonanza. And he runs Russell Street Ventures and investment firm that includes other people who have been in this position. So I won't get too far into this, but basically this little think tank within the Medicare program is now run by this woman under the Biden administration. And she has a history of working for the private insurance industry and the pharmaceutical industry. That's her history. So your question in the back, your theory was that this could be ideologically driven, that we're privatizing our public programs. It's also possible that it's personal self-interest and cronyism. That's the alternative theory. However, I don't reject your idea. I accept your idea. And I think ideologically driven to privatize everything, certainly was it manifested since Ronald Reagan took office in particular. And so the ideological idea is possible. But we're also seeing a whole lot of conflicts of interest among people who are in powerful positions. So yeah, she was a well-pointed insurance company. And she helped design Obamacare, which is privatized basically similar. The exchanges are similar to Medicare Advantage. And then the insurance pharmaceutical industry, too. So here's the program that this Jared Kushner friend came up with. It was called DCE Direct Contracting Entity. Just got its name changed to ACO Reach. We can talk about what the name means, but the point is what the program does. For each primary care provider who has signed a contract, CMS automatically aligns, in other words, dumps every patient that that primary care doctor has who's over 65. They get dumped into this DCE program or ACO Reach. And so the Medicare money is no longer going to go directly to your doctor. And I'm talking about people in traditional Medicare. If you selected a Medicare Advantage plan, I'm not talking about them. I'm talking about people who are paying $2,000 a year, in most cases, to not have a Medicare Advantage private plan. But you're getting one. And you're dumped into it automatically. You're given very little information. And what there is is extremely misleading. We'll get to that in a second. But you're dumped into these private programs. And the Medicare money is now going to go to the ACO Reach company. And that your doctor signed a contract with. And your doctor is going to be paid so that the more medical care you get, the less money you get if your doctor's signed up with an ACO Reach. They're going to get various types of bonuses. Can I ask a question? Yes. Can we get these private insurance companies out of the picture? Just subtract them. They're out and have a system that deals with the patient, the tax system, and some kind of a legitimate mechanism for figuring out who's sick, who needs help. You'd rather be private insurance companies out of it completely. OK, so I'll answer your question in two different ways. One is administratively. For example, are there countries where the government ensures everybody directly, pays doctors and hospitals directly? Many countries. Those are called single payer systems. It's the majority of developed countries, Spain, France, Sweden, Italy. Many countries have such a system. And they work in Taiwan. They work very well. And so if your question is, can it be done and be successful? No question about that. That's what single payer health care is all about. If your question is, is it politically feasible in the United States? That's a question we maybe discuss later. But I think it will take a political movement. People have to be out in the streets. No, we were out in the streets. And we do have the legislature passed in Vermont, but we don't have any money to fund it. So Vermont has universal health care as a right. Thank you. It's written, but we didn't fund it. So Vermont worker center is trying to get everybody active again to look at funding it. But do you think that can happen here in the United States? So we can go past or get past the cause of all those lobbies? Yeah, there are obstacles to state-based reform, but that's another issue. I think it would take a very powerful political social movement. And I'll get to this later if you want, but I'm not as pessimistic as many people are about whether there can be an effective social movement. So the growth is driven by contracting with more primary care doctors. Patients have no choice. And patients, as I said, are not even really fully informed. And there's no patient consent. You're in. You're just in if your primary care doctor signed up. And the only way to opt out, find a new primary care doctor. I just want to say, I teach a course in the summer. Betty and I teach a course. And we actually had Liz Fowler, the head of this whole program. And we said, well, how can people change? How can people get out of this DCE thing? And she actually said, they can just change doctors. It's like no different from changing your brand of toilet paper or dishwashing fluid in my book. It's not easy to change a primary care doctor. Yeah, I think it's like, where is she living? Anyway, so let me just get beyond this one. Providers collect 80% from Medicare Part B and 20% from the patient in traditional Medicare. And DCE reach, much more complicated. The primary care doctor, let me just say, it's extremely complicated how your doctor is paid. But the goal is to have your doctor lose money the more medical care you get. It's a disincentive. And I think this is ethically very problematic. So Medicare health spending. So what's going on here is the DCE company is keeping a whole lot of money if they succeed at not spending of cutting the amount of health care you get. They make more money. That's basically what the slide is showing. We don't have time to get into it. It's very complex, the formula, but they're making more money if you don't get much care. Here we go. We can get into this later if you guys are interested. Margaret, can you talk about how the whole Medicare trust fund is drying up? The money is big. There won't be any money in here. I think we are seeing a lot of this. Anyway, so as of 2021, there were 54 DCEs, 340,000 beneficiaries. 2022, they're up to 1.8 million. And then it got renamed, reach. And there's no limits on expansion. And Liz Fowler, the current director of this think tank she's trying to get every single Medicare beneficiary in DC or in a Medicare Advantage plan by 2030. That's her goal. Wait, is that a goal or is that a requirement at this point? That you're in one or the other. Either take Medicare Advantage or not. So let me just point out that when Liz Fowler said that, oh, you just changed your primary care doctor, that was in the same framework as saying, but they'll all be in these by 2030. So there will not be any primary care doctor available to change into. You're going to have to sign in. So the same strategies we saw for the Medicare Advantage plan, but no more Joe Namath because they don't need to do TV ads because you're automatically in, they have to get primary care doctors to sign on. So that's how they get more people. No consent involved. And how are patients informed? This letter is appalling. This is the letter you get. It's appalling. And for those of you who want to see it, I can email you this slide. Anyway, it's so misleading. It's like unbelievable. Is there any on to this? He's opposed to it. Yeah, but I mean, is he, is he in any colorful position? Do anything about it now that he's care of the hospital not dealing with it? Well, I don't know if he's going to have a, you know, see if he goes to the sign-in. We'll go a little later because I have to be behind and Tom needs some time. So again, maximizing revenue. We already talked about how they roll fee. We'll get more primary care doctors to sign on. How they get more revenue per patient, risk coding. She may not look sick, but she's really sick. And we'll code her really high, find a way, you know. She's faking. She just wants to not go to school. Anyway. Like doctors are you done? So the DC will attempt to build in disincentives, capitate the primary care doctors make it so they earn less money if you need a lot of care. Additional risks, people in traditional medical care are allowed, there is a network, but you're in traditional medicine who are allowed to see any doctor you choose. But when the DCE plan or the REACH plan is implemented, your doctor will lose money if you go to Mass General for that knee surgery rather than going to Garland. Your doctor will lose money. So your doctor is now in an ethically dubious, it puts the doctor in an ethically dubious product and the patient then doesn't know. So middlemen deliver less care, retain higher profits. Even private equities is very involved in this. Financially risk you for positions, it's the least of the problem. And I just talked about the conflict in the treatment. When does the AMA stand up to this bullshit? The primary care? Yeah, well, some of the AMA people are domestic. Some doctors are making more money by doing this. And there's a segment of doctors who are kind of macho and they feel like they can, I can keep my patients healthy. And so they feel like this kind of contract will do better or it may be ideological. So a lot of doctors in these states are employed. They come out of school with huge debt and they are not in private practice. If you were in private practice, you would have a choice of not signing these contracts. But if you were employed by a hospital or by a clinic or by a managed care organization or whatever, you have to do whatever your employer says or figure out how am I gonna go out on my own? What am I gonna do instead if my employer is requiring this? And they also are really busy same patients. They don't have a lot of time to research this. Your after-sculpture patient does not know as much as you will know at the end of this. So I have some cases we could go over, but I'm gonna give a floor over to Tom. So if you want to thank you, Ms. Tom Applenauer is a legislative coordinator to the Broad State Employees Association. As the coordinator, he lobbies on the members' behalf at the State House, the National Association and runs the PSGA political and electoral program. He'll be speaking about the latest news about the governor's plan to force state retirees into Medicare Advantage plans against their will and to discuss the current state of the efforts to fight back against that proposal. Thank you so much for being with us here tonight. Thank you so much. I want to thank the lead on this program. Dr. Malak for his incredibly informative presentation. I am familiar, unfortunately, more than I ever had been before with the horrors of Medicare Advantage, but this presentation tonight is thrown into really stark relief. In a way, this is bringing things full circle for me. When I was a law student, I was a staff member at the Center for Medicare Advocacy, trying to ensure that seniors were receiving the care that they should and the proper insurance they should. I never anticipated that 10 years later, I would be fighting that fight all over again. So as a background for folks, they said I'm with the State Employees Association. We represent about 6,000 members across the state and several thousand retirees. And state retirees, I've seen several state employees and state retirees in this room. Hello, welcome everyone. Thank you for coming. The way that the insurance works currently for our retired members is that Vermont state law guarantees very unambiguously that our retired state employees will receive the same state insurance that is bargained by their sisters and brothers who are active state employees when they are retired. So any state retirees in this room are aware of this. My mother who was on that plan, as a result of my both, my parents were state employees, my father's side was a social worker, my mother worked for the Department of Health. My mother still receives her Medicare wrap around coverage through that plan. So one would think that given that unambiguous language in the statute that there would really be no question about this issue. But unfortunately this summer, we at the union at VSEA received a contact from members of the Scott administration and they came to us with the phrase that whenever we hear it uttered by this administration, it gives us chills and not in a good way. They said, boy, do we have an idea that you guys are going to love. Whenever I hear that, I immediately start having heartburn. They said, well, we're going to transfer your retired members into Medicare Advantage plans. And we think we can save the state several million dollars. If we do so, and wouldn't that be great? It would mean that we could spend all this additional money on the programs that all of your members work for. And we had to immediately push back and say, actually, no, that would not be great. We would not prefer to see the state insurance plan, which we are entitled to under law and which our members have been promised as a result of their state service, many of whom have trading away more lucrative careers in the private sector in order to secure that insurance. They said, no, that wouldn't be a great idea. And what's more, the statute says that you can't do that. Many more intelligent and well-seasoned attorneys than myself also looked at it and said, yep, that's really unambiguous language. The language for any wonks here in the room is in three, VSA, four, seven, nine. And it says very clearly that state employees who retire will receive the state health plan. That state health plan, as I mentioned, is bargained by state employees with the state. And it's administered by Blue Cross Shield at the moment, but that is not a Blue Cross plan. It is a state plan that is bargained by our members. So the administration says, well, we think we can do it anyway. And in fact, we're planning to do it by January. That was their stance at that time. So, you know, we had a team of lawyers look at the statutory language, and they confirmed that our reading of it was correct, that that change could not be made. And we said as much to the administration and made very clear that we were willing to defend our position on this matter in court, if it should come to that. When the administration started, it seemed to get a bit of cold feet. And they said, well, we're not gonna do it by January, but we probably will do it by the end of the legislative session. And we'll talk about it, but we think we're still gonna pursue it. So we then met with our legislative partners. As was said, I represent state employees at the state house, I lobby on behalf of the state employees association. And we had conversations with folks in legislative leadership who reviewed the statutory language. They agreed with us. They said, this is very unambiguous. And what's more, even if there were not this statutory language, it would not be appropriate to force retirees into these plans, which Dr. Malick has very, very articulately described how terrible they are. Wendell Potter, a former health insurance CEO from, I believe, ECNA has called the Medicare Advantage plans the greatest fraud that has been perpetrated on the American taxpayer in the past 50 years. That's a paraphrase, but that's largely what he said. These are a disaster and they're being sued for fraud and for not providing the promised care all around the country, particularly Cigna, the provider that the administration says they want to force our retirees into. So, I'm out of legislative leaders and I have a copy here of a letter that we were able to secure in consultation with our legislative partners, where Speaker Jill Kroinski and president pro tem of the Senate, Phillip Baruth, wrote a letter to the administration saying, we have reviewed this language. We do not believe that you can make this change without legislative approval. And by the way, if we have anything to say about it, that is legislative approval that you will not get. That was the letter that was delivered, open letter delivered to the administration saying, we do not support this change from Senator Baruth and Representative Kroinski. We had thought that that statement in conjunction with the analysis of the legislature's own attorneys who have testified in the Senate Government Operations Committee and other committees in the legislature, the Office of Legislative Council, which is sort of like the legislature's own law firm has reviewed this language and they agree with our position that the administration cannot make this change without a statutory change. We had hoped that that might give the administration some pause and cause them to abandon this plan. But that I guess was wishful thinking because after this presentation was made and after all of this was discussed, the administration nonetheless held a press conference the other day where they said, well, we are still gonna move forward with this proposal. We're still gonna, we think we can do it. We don't think we need your help to do it and we're going to do it. And the theory that they're arguing for as to why they can ignore the plain statutory language in the law, statutory language, excuse me, is that they say, well, it says that they have to receive, we think we're complying with the spirit of the law, if not the letter of the law, because we'll put them into Medicare Advantage plans that will have all the same benefits that the state plan has, right? This is problematic for a lot of reasons, right? Obviously we've seen that they may deny folks benefits for what they promise. We've seen that it's very, it will be very difficult for them to, even if they were to attempt to earnestly to keep up with what is in the state plan. And furthermore, Dr. Mount spoke about the ability to go back and forth between Medicare and Medicare Advantage plans. That does not exist for the state employees plan. When someone leaves the state employees plan, they leave it for good, right? So they would not have the ability to float back and forth between them. So, we have had, part of the reason I want to come to speak to folks tonight is I know that folks wanted an update on where this battle stands, as it were. As I said, legislative leadership has been very clear. They've been speaking to folks in the administration about this. They've been making their position very clear. And although that doesn't seem to have deterred the Scott administration, it does seem that we are in good legislative standing there. However, folks in this room have already contacted their legislators. There was sort of a groundswell of opposition to this proposal very early on. That has made a difference. This proposal, I'll be blunt, is very unpopular in the legislature. But we're not going to stop there, right? Because although the current statute says that the governor cannot make this change unilaterally, they continue to pursue it. So what might that mean? If they said, well, we're doing it anyway despite the legislature's position, despite the retiree's position, we're just going to jam this change through, what could they do? They could do it, and then we would be in a position where we were forced to take legal action. So to prevent even that possibility from coming to pass, we have advocated for language to be added to the budget in both the House and the Senate that would explicitly, beyond even the very clear statutory language that's already in place, say to the administration, there's no way you can do this, so don't even try. And the Senate Government Operations Committee the other day had a meeting where they had bipartisan unanimous support that language like that be adopted by the legislature this session. So there is good support from folks in the legislature and fortunately, I think both the groundswell of retirees like many of the folks in this room, advocacy in the building and support from folks in the legislature has made it, I think, very difficult for the administration to succeed with this very ill-advised and frankly, in my opinion, morally treacherous plan, right? These are the plans that people have been told, their entire careers of public service they would receive to be members of the state plan and to have that bait and switch pulled to the last minute I think is really reprehensible. And I'll just say, I'm a candidate for city council here in Montpelier and as I go around in this district which is full of state employees, I've met many of our retirees and folks are very, very scared, they're very scared. I had a gentleman reach out to me in my capacity his legislative coordinator and say to me, you know, I receive care currently at Dana-Farber, Dana-Farber will not accept this Medicare Advantage plan. But someone say to me, I'm on supplemental nutrition which because of the unique circumstances of my own personal care has to be delivered not through a feeding tube but orally as it were. And that my unique circumstance is such that I can have that covered under the state plan but would not be able to have it covered in the Medicare Advantage plan. So a lot of the most knowledgeable advocates of what the detrimental effects of this would be are the folks of course themselves who it's a life or death matter that they know whether or not they'll continue to get this care. And when I speak to folks on the doors as I've been knocking doors this week there are a lot of people who are very scared. And so I think it is essential that we continue to ensure that folks in the legislature are standing firm on these positions and I think they are. I think it's essential that we continue perhaps most importantly to contact the governor. So we've had many, many of our members, the governor, yes. Contact the governor and tell him to abandon this plan. This plan to support the privatization of Medicare. This plan to siphon money away from retirees and put it into the pockets of middlemen. This plan to attack seniors' healthcare which one would have thought traditionally was a political error that no one would be so silly as to step into. But the administration seems hell bent on it so we need to keep calm. So I would suggest that anyone in this room who is either concerned that they're going to be affected personally or who would like to act in solidarity with these public servants to ensure that they are going to receive the insurance that state law, the state of Vermont for many years and morality says they should continue to contact the governor and ask him to abandon this plan. Just because I know there are several state employees in this room and state retirees in this room, I will say that we are having a Medicare disadvantaged lobby day at the state house coming up on this Wednesday where there'll be a whole day of programming. There'll be a press conference that'll be held with members of the VSEA. Dr. Malik has been kind enough to join us for that event. Former Secretary of State Jim Kondos will be speaking and our members will be testifying in committees across the building about what a misguided idea this is. So that should be, there'll also be a dinner held that evening, a legislative dinner where members of the VSEA and other folks who are interested will be able to meet with members of the legislature to talk to them directly about our attempts to kill this proposal. So I come to you with optimistic news, right? It does seem that, there was a question before and unfortunately I know the person who asked it has had to leave, there was a question before about what can unorganized political movement do to fight these changes to Medicare? How successful can we be? Well, I think this is a microcosm of the national situation and it shows that if we do organize successfully, vehemently and really push back hard and demand the kind of care that people deserve, we can have success, we can have success but it requires advocacy. And some of the folks in this room have been a big part of that advocacy vote so far and I think let's see there's a question. Two questions actually, one is why do you think the Scott administration is doing this? Two, isn't this a wonderful argument for the single-payer program or a universal kind of care? It's one of those but as you know I'm writing for it. Yes, yes. As are several of the VSEA members in this room, the VSEA feels that all Vermonters should have the ability to have the same kind of excellent care that they receive through the state system. We hope to bring everybody up to the level of that which our members enjoy and that they've earned through the collective bargaining process but to go to the first question if you're asking me to speculate as to why the Scott administration is pursuing this, I wanna be very clear, well yes, I heard someone say $12 million over there, there have been discussions about $9 million. As with many efforts in privatization, a lot of the purported savings may never materialize, that's been a sort of national story. I'm not the Scott administration spokesperson and I don't intend to speak on their behalf but I will say that throughout this administration we've seen two things happen regularly sort of across the board, there was a talk before about ideological support of privatization. There has been an effort on the path of this administration and unfortunately previous administrations to privatize everything that is not nailed down, that there is a belief that if someone in the private sector can be a part of getting some of this money that they ought to be and that a private entity can support things in a more robust way then can the government. A view that I'm sure nobody here will be surprised to hear that the staff person from the State Employees Union does not share, right? I don't believe that government, it can be outperformed by the private market. So I think that there's an unfortunate trend in this administration towards privatization and the pitch to the legislature has been think of all this money that we can save which is a dubious question at best. I see a bunch of hands so I'm gonna rotate around, yes ma'am? Hold on a second. Is there such a thing left as a traditional private insurance company like Goodforsha Field or have they all, do you mean to say are they all participating in the Medicare Advantage plans? I'd have to defer to Dr. Malick on that question. I mean because we still have, we still have Remount Blue 65 and to my knowledge it's not a Medicare Advantage because we're in Medicare and supplemental Remount Blue 65 we're not in Medicare Advantage. Before I get, I will answer your question but before I do I want to invite Betty to explain something namely what this is about before you do it. Before you do it, so we're five minutes over and I think Tom are you willing to stay 10 more minutes? Happy to stay as long as possible. So we'll stay at least 10 more minutes to answer additional questions including yours. But let Betty talk first. So this is a QR code and if you haven't used one, if you've used one before I apologize for spending so much time on this but if you have never used this before you can hold up your phone to it, turn on your camera and aim it and you'll see like a little like blue or green outline around it. When you hold it still and you get that outline then you can click on it and that can save it for you to look up later or it will work and just go to the website right there, you might have to click on one but one menu option. And then it'll be opening in your browser so you can get to that layer and just look at your browser. Does that make sense to you? There you are. Is that what happened to you? Yes. So where is that going to take us? It will take you to a, is this the Protect Medicare website? Okay, so PNHP has the regular website and then they have another website that's dedicated just to protecting Medicare because they really want to get a national health program for everybody. This is not getting a national program this is just protecting what we have so far. So this will take you to a site that will tell you what you can do like signing petitions, telling you, you know, sending letters to your legislators, that's the good thing. And to have a reference, if you tell somebody else, gosh, I went to this talk with Martin Malik but I can't actually repeat what he said. Then you can send people there and they can watch a video or something like that. That's just possible. That should be the same stuff. If our phone died, where, what's the website? Oh, protectmedicare.net of things. There's a petition on the website to oppose the privatization of traditional Medicare in particular, which is the last part of what I was talking about. People who are choosing not to go to a Medicare Advantage plan are going to have managed care dumped on them anyway in this REACH program. Which I just, it's so appalling, it's unbelievable. So please sign that petition. I'm sorry to give my opinion. I thought that was about the sum of the people that you were talking about and how it's going to be automatic. So this, right, so this QR code is not about Medicare Advantage, this QR code is about the DCE program. And so it's that program where you will be getting a letter telling you that you're going to be put in this ACO and this is the number to call if you don't want to do it. When you call there, they'll say, you have to choose another doctor. So this is about that DCE program, not about military management. Let me get back to a question over here about Blue Cross. Blue Cross offers both a Medicare Advantage plan and a supplemental plan. So they have both types of plans that are offered. I don't, Blue Advantage, I think is their Medicare Advantage plan. And I don't know what the supplemental one is called. Yes. Oh, thank you very much. Thank you for being here tonight. Both of you, this is huge. The reason why it's huge is I worked with the state of Vermont for almost 40 years. I have been an incredibly active retiree for the last three weeks. And I know a lot of legislators, I spent a lot of my life up there when I worked and we really need full core press to continue. Thank you for your awesome work, Tom, and we'll talk afterwards. But here's the question. Any of us who can read are aware of the stories of the New York Times, the Atlantic. That gentleman you mentioned who's got the, sort of the whistleblower, the newsletter he has on. Thank you, Mike. All that stuff is out there. Even Vermont Digger has some stories. Knowing what we all know, maybe not at the level we know even more so, thanks to you tonight, Dr. Maylach. Why would the UVM administration switch their retirees to a Medicare Advantage plan? Why would the state, why would the teachers group switch to that? And why would the Phil Scott's administration want to make that switch, knowing it's such a scam, knowing that it is bad ultimately for sick people, especially us as we're getting older and older. Why did people make that change? What is it? I'd like to go first and let Tom follow me if you don't mind. What are we not seeing here? Okay, so there's a lot of flows of money going on with this insertion of a middleman. So if you're an individual, not part of a union, but if you're an individual, and you're choosing to go into a Medicare Advantage plan, you're paying less upfront, but much more if every time you get medical care, there's gonna be a copayment. And depending on who you're going to and what type of care it is, the copayment may be minimal, like a preventive visit to your primary care doctor, your copay may be nothing. On the other hand, if you're going for some cancer surgery, your copay is gonna be really big. You're gonna have to pay part of the hospital bill and part of the surgeons bill. So your bill is gonna be very big. If you manage to stay within the Medicare Advantage plan's network, you have an annual maximum $8,300. So if you get diagnosed with cancer in November one year and you're in a Medicare Advantage plan, you could have spent $16,600 within four months out of pocket. So that's what a Medicare, so the out-of-pocket payments when you're actually getting care are quite substantial, whereas if you have supplemental coverage, they're zero. So you're limited to where you can go and you have a lot of payments when you choose to do that. That's not my question. No, I'll get to your question. So the entry costs into the program for an individual are for a Medicare Advantage plan rather than a supplemental plan are much lower. Instead of being $2,000 a year, they might be 500, they might be 200, and in some zip codes, they're zero for some Medicare Advantage plans. That's the amount of money that the state of Vermont would pay to get you into a Medicare Advantage plan. You're gonna have to pay the money once you, when you go to get medical care. So they're transferring the cost, the cost to you of all these co-payments. So it's all about money. It's about money. It's about money. That's right. And just specifically to the teacher's case, because I know there was a question about the teachers that were doing the Medicare Advantage, I'll be very brief. And again, I don't intend to speak on behalf of the teachers tonight, but the teachers did not have the same statutory protection barring such a change that the state employees had. So that's already happened? Yes, that's correct. Yes, that's when the glitch. Yes ma'am, go ahead. There was a glitch when that happened because that's what I'm in. Yes. And what we had before they made that change, which was with the supplements of Blue Cross, we got to keep that because they couldn't just figure it out. They couldn't sort it out. So we're not stuck in the Medicare Advantage plan. We still have our traditional Medicare and the stuff we still ensure. We don't know how long we're gonna keep it. We don't, they haven't figured it out. Something went screwing, but to our advantage. I want to share something to make sure you all understood that and then ask you a question. So if you go straight on to Medicare, traditional Medicare, then you don't, you get the supplemental plans that give you a certain rate that you have to pay. If you go to Medicare Advantage, then you do that for a while and you decide to go back to the other. You now have to be assessed for like how much more expensive you are because you're sicker, because why do you need Medicare Advantage? So you'll pay a penalty for the rest of your life for every one of those premiums. And so my question, and that's actually something I just thought of tonight. A single payer, if the single state doesn't have payers, what happens when somebody moves to another state, like your kids live somewhere else, because I go somewhere more, what happens for getting your Medicare in a different state? But anyway, so back to the question here. What happens if a state employee or a teacher, if they were forced onto the Medicare Advantage program and then they wanted to get out later? If they wanted to go back to the state plan, they would be unable to. They would be unable to. They would be unable to. Once you leave the state of Vermont's plan, you cannot return. But if you couldn't leave, you couldn't stay on it because you were forced off, but you still can't get back on it. Correct. Well, if we have to, we will. But hopefully it doesn't come to that because hopefully we're going to get very clear language even beyond the incredibly clear language that they're right now explicitly barring the administration from doing what they're trying to do despite what the law says right now. Should we do part of it just to do something like this? Yeah. Yes. Is it possible to as well reach out to you with any follow-up questions? Absolutely. So I know that not everyone has a pen and a piece of paper and unfortunately I'm without cards. But for anyone who has it, my name is Tom Abdelnor, which is A-B-D-E-L-N-O-U-R. And you can follow up with me at my work email, which is T-A-B-D-E-L-N-O-U-R-AT-V-S-E-A.org. Thank you. Sorry, it's a bit of a mouthful. I like this. So we were to make a mistake. You can use mine now for me. And I have one follow-up question. I have one follow-up question for the judge. You mentioned before that you're not entirely unoptimistic. Do you have some optimism in regards to the future when it comes to ACO reach? And I'm just wondering if you can say a little more about that and or sort of big picture beyond signing petitions online, what the movement could look like from your perspective to reverse this change and strengthen traditional Medicare, strengthen supplemental coverage. Okay, for those of you who were born after 1965, your consciousness would be developed around 1980 and thereafter. And you have seen a 36-year-long period, 1980 to 2016, that was politically very stable. We've had what by international standards is a right wing or even far right compared to Germany, England, and all the other developed countries. We've had a far right regime operating that even when there's a Democrat elected president, they effectively don't challenge it. Look who Biden has appointed to be the head of his think tank. You know, an insurance industry person. And she'll go back to an insurance industry when she leaves. This is a revolving door, and that's the corruption. So, you know, regardless of whether it's ideological or corrupt, it needs to change. But this is what we've seen for 36 years. There's unrest in the country because that 36-year regime, its policies have promoted significant income inequality that worsens every year. Similar regimes have happened in other countries to a lesser extent, so income inequality is worsening worldwide, especially in the U.S., in Brazil and a few other countries. And I don't think it's stable. It leads to social unrest. Let's go to the example of Germany. If you're in Germany in 1905, the Bismarckian regime, Germany had grown tremendously, was becoming a powerful country under Bismarck and other, you know, that regime of the Kaiser. Who would have imagined in Germany in 1905 that they would be in the trenches in France with poison gas 10 years later? If they were in the trenches, how many of them would have guessed that 10 years later, there would be hyperinflation, so people would be moving German marks with a wheelbarrow, you know, with tremendous unrest. 10 years after that, Hitler was the wonderful promise of Hitler, you know, 1935. Everybody was, you know, feeling excited that the country was changing, moving ahead. You know, industries were growing. You know, five years later, Hitler was on the tank in Paris, you know, and the Germans largely were ecstatic. And five years after that, the entire country was leveled. It wasn't just Dresden, it was Berlin. Whole country was completely leveled. 10 years after that, there were progressive country, you know, in the European Union. Social change is somewhat unpredictable and can be wrenching. But in the US, we've had 36 years and to some extent, the Trump regime isn't that different. It has features that are different, profound anti-democratic tendencies that we didn't see, you know, with previous Republicans. But so that's disturbing, and it's a change. But so the country could change dramatically. And so my role in this, and the reason why I teach, especially the medical students that we teach every year, is so that when things start to change, we have useful ideas that have been gone over, that have been tried out internationally, such as single-payer health care. And that we know, and that we have a vision that things can be better. And that we, when the opportunity comes that we're gonna fight for it. And I think we should all be organizing now. I think you should, you know, get on, sign this petition, right, you know, make Becca Bellin make sure she keeps her promise to our group. She met with our group. She said she was on our side with us. But, you know, let's keep her, keep her honest. Let's make sure she does it. And I think find ways to be active in movements that you care about, and this is a good one. So I want to remind people that the Medicare Advantage Program is something that's been into legislation in the U.S. Congress. And so to change that, the law has to be changed. So that's where you would focus your efforts, okay? However, this DCE program is not, it's allowed by the ACA, but it's not created, is not required by the ACA, so all we need to do is actually persuade President Biden or Secretary Becerra, which we don't need to pass any laws in this dysfunctional conference. So that's where you focus your efforts for that kind of work. I wanted to also just make an announcement about an event tomorrow, and then if people have more questions for either of our folks to read, but I wanted to make an announcement. This is what I'm adding now. I want to make the announcement before everybody leaves. So there will be an event Tuesday tomorrow, February 7th at noon in civilian 270, with an event to teach about the universal primary care bill. So it'll be Representative Sina, Ethan Park, K-Cast, I don't have a lot worker center, and a variety of other folks who will be talking about what's in the universal primary care bill. That will be screened on YouTube, you can't get into the state housing in the day, but it's at noon, but it'll be good. Here's a copy of the bill if you want it, I've got you a copy. And as I mentioned before, this coming Wednesday will be our Medicare disadvantage day of action at the state house. 11 a.m. is the press conference. It'll be events throughout the day. It'll be testimony from VSEA retirees at 9 a.m. at 3 p.m. There'll be a legislative dinner that night. Anybody who's interested, feel free to reach out to me. I'll be happy to provide you with all the information. Thank you.