A President for the Worst of Us

Violence “on many sides, on many sides”. He had looked up from the lectern and some viewed it as off-script, an ad lib. By suggesting there was an equivalence on both sides — neo-Nazis and white supremacist bigots on one side and those who had come to Charlottesville to protest against their toxic message — President Trump begin three days of disgracing the presidency with progressively worse arguments and stunning unawareness of what country he lives in.

He condemned “in the strongest possible terms this display of egregious hatred, bigotry and violence” without naming the groups or even which groups he was talking about, his primary concern being not to offend his white nationalist base. He was prompted by the press to say more, with one asking “do you want the support of these white nationalists”, but he passed up the opportunity and simply left the room.

The neo-Nazi group, the Daily Stormer, was exultant:

“He didn’t attack us. He just said the nation should come together. Nothing specific against us. When asked to condemn, he just walked out of the room. Really, really good. God bless him.”

Former Grand Wizard of the Ku Klux Klan, David Duke, tweeted:

“Thank you President Trump for your honesty & courage to tell the truth about #Charlottesville & condemn the leftist terrorists in BLM/Antifa”

He was referring to Black Lives Matter and the anti-fascist group.

His advisers pressed him to make a stronger statement. Not until the Monday after the Saturday did he call out any of the groups by name — “the KKK, neo-Nazis, and white supremace [sic] and other hate
The torchlight procession the night before the rally. An unmistakable echo of Nazi Germany

groups that are repugnant to everything we hold dear as Americans” — reading from a script. He evidently thought that three sentences — read grudgingly at that and two days later — should be all there was to it. When the media furor continued, he tweeted:

That anger boiled over on Tuesday when he went entirely off script. In a presentation that was supposedly about infrastructure he again became the persona he is known for: his own worst enemy. Winston Churchill once said of John Foster Dulles that he was a bull who carries his china shop around with him. Were he alive today, Churchill would substitute Trump.

“What about the alt-left? They came charging at the, as you say, the alt-right. Do they have any semblance of guilt?”

For him those counter-demonstrators against Nazis and bigots are extremists now to be known as the alt-left, and note that the alt-right only exists “as you say”.

It was his characterization of the groups that had come to Charlottesville to protest the removal of the statue of confederate general Robert E. Lee that was most astonishing.

“I looked the night before [Friday]. If you look, there were people protesting very quietly the taking down of the statue…people who were very fine people, on both sides.”

The fine people on one side were marching on Friday night in a torchlight parade unmistakably copying the symbology of torch-carrying Nazis of the Third Reich, some of them issuing raised arm Nazi salutes, uttering fascist watchwords such as “blood and soil”, and chanting “Jews will not replace us”. What, for Trump, was the equivalence on the other side?

And yet, reported the Associated Press, “The president told associates he was pleased with how his press conference went, saying he believed he had effectively stood up to the media”.

A week later, he went to a rally in Phoenix where he recited his earlier disavowals of hate groups, but he left out the “many sides” and “fine people” phrases with which he had elevated the white supremacists and neo-Nazis to parity with those protesting their bigotry. The Phoenix crowd, roaring their adulation, showed no signs of knowing the difference.

nothing new

When Trump challenged the legitimacy of Obama’s presidency with doubts he had been born in the U.S., he chose to join the right-wing conspiracy mongers who were outraged that a black man had become president. He may have foreseen this only as a canny political move, a wedge issue to win the support of that contingent, but who would be comfortable taking that tack other that someone who held those views himself.

His televisions series, “The Apprentice”, had won him a strong black following — there were black contestants on the program and one had won in season three — yet Trump was ready to throw them over now that his ambitions moved up a notch. Taking the lead of the birther movement, he sent a signal to white bigots that — as he would later say at the nominating convention — “I am your voice”.

He was not shy in his pursuit of a white following, pressing the issue on television. “I’m starting to think that he was not born here”, he said of Obama on NBC’s “Today Show”. “Why doesn’t he show his birth certificate?” he asked on ABC’s “The View.” “I want to see his birth certificate,” he told Fox News’s “On the Record.” Trump told Meredith Viera, host of the “Today Show”, that he had sent investigators to Hawaii “and they cannot believe what they’re finding”. There were no investigators, of course. The Hawaii state registrar said he had “no evidence or recollection of Mr. Trump or any of his representatives” ever requesting records. But the trick worked to sow doubt in gullible minds. We would much later learn how at ease Trump is at spinning lies.

He insinuated that President Obama held back after the Orlando terrorist shooting, saying on Fox News that Obama doesn’t understand Islamic terrorism, or “he gets it better than anybody understands…or has something else in mind”, a dog whistle to those in his base who think Obama is a Muslim and a Muslim sympathizer. In 2014 he tweeted, “…because president Obama has done such a poor job as president, you won’t see another black president for generations”.

He infamously accused Obama of “wire-tapping” Trump Tower in New York. He has engaged in a campaign to unravel every one of Obama’s accomplishments. Is that just childish revenge for Obama having paid back the birther slurs when he ridiculed Trump at the White House Correspondents Dinner in 2011, or is Trump bent on removing every trace of a black presidency?

From early on, Trump was no racial innocent. He was involved in a discrimination dispute at age 27 when Trump Management Co., run by his father, Fred Trump, was sued in 1973 by the Justice Department’s Civil Rights Division for schemes to prevent renting its housing units to black families. Some employees said they had seen no such practices. Others said rental applications were coded to indicate black persons or income requirements were doubled to turn them away. One employee was told by Fred Trump himself to screen applicants and not “rent to blacks”.

Young Donald called the charges “such outrageous lies”. The case was resolved in a consent decree whereby the Trumps admitted no wrongdoing but were prohibited from “discriminating against any person in the terms, conditions, or privileges of sale or rental of a dwelling.”

never wrong

In 1989 five black and Hispanic teenagers from Harlem were accused of beating and raping a white woman jogger in Central Park. The outraged Trump spent $85,000 on full-page ads in the New York newspapers calling for the death penalty. “Muggers and murderers,” he wrote, “should be forced to suffer and, when they kill, they should be executed for their crimes”. The Central Park Five had served from 5 to 13 years in prison when exonerated by DNA evidence but Trump has never apologize and, as someone we now know is too lacking in morality ever to admit he is wrong, still insists they are guilty.

During the campaign, Trump was confronted by CNN’s Jake Tapper, who three times asked him to condemn and decline the vote of white supremacists and David Duke. Trump feigned ignorance of both. “I don’t know anything about David Duke. I don’t even know anything about what you’re talking about, with white supremacy, or white supremacists.” Asked again, “I don’t know what group you’re talking about”.

Tapper finally said, “I’m just talking about David Duke and the Ku Klux Klan here” to which Trump answered, “…honestly, I don’t know David Duke. I don’t believe I have ever met him. I’m pretty sure I didn’t meet him. And I just don’t know anything about him”.

Those were several lies. In 2000 he had considered running for president on the Reform Party ticket. But so had Pat Buchanan and his supporter David Duke. Trump withdrew, thinking it ill-advised to be in the same company. He hadn’t yet intuited that embracing white resentment and white nationalism would be his path to the White House; he knew enough of Duke to call him “a bigot, a racist, a problem”.

otherness

Trump’s animus has been directed at not only blacks but at every non-white race and ethnicity. He infamously opened his campaign in 2015 by calling Mexicans coming into the U.S. criminals and rapists.

“When Mexico sends its people, they’re not sending their best… They’re sending people that have lots of problems… They’re bringing drugs. They’re bringing crime. They’re rapists. And some, I assume, are good people.”

Just some. He would claim he couldn’t get a fair trial in the class action suit for fraud against so-called Trump University from a Mexican judge — a judge of Mexican lineage but who in fact had been born in Indiana.

He spoke of deporting all 11 million Latinos and once in office his Immigration and Customs Enforcement units would be set to work raiding homes with less concern about breaking up families than Obama’s program of deporting criminals, his Justice Department would threaten to withhold funds from sanctuary cities, and what is expected to be a vast purge of voter rolls would begin, its assumed intent being to eliminate Democratic-voting Hispanics, moving well beyond the restrictive laws enacted by Republican-controlled state legislatures across the country to hinder blacks and Latinos from voting.

Trump’s calling marchers carrying torches and chanting against Jews “fine people” brought to mind his tweet of a picture of Hillary Clinton on top of a pile of cash and a six-pointed star. In a speech last October he warned that Hillary Clinton “meets in secret with international banks to plot the destruction of U.S. sovereignty” and that “a global power structure” is conspiring against Americans, tropes that historically have forewarned of a worldwide Jewish takeover plot. The final ad of his campaign had an “elders of Zion feel to it” for Senator Al Franken, depicting three “people who don’t have your good in mind” — George Soros, Janet Yellin and Lloyd Blankfein of Goldman Saks — all of them Jewish.

Blacks, Latins, Jews and days after taking office, Trump imposed a 90-day travel ban on the people of seven countries, making good on his campaign promise of a “Muslim ban”. The professed reason was a pause for developing “extreme vetting” protocols to safeguard national security. That lie traded on public ignorance of a vetting process already so extreme as to take two years which made legal application for entry to the United States for the least sensible way for an al Qaeda or ISIS terrorist.

The courts blocked that as well as a second attempt against six countries that tried to scrub inferences of Muslims to get past the Constitution. Trump persisted until the Supreme Court let the ban go forward pending review this fall. But the 90 days had come and gone twice over, giving the lie to the extreme vetting fiction. It’s a travel ban against Muslims.

the company he keeps

As president he has chosen as advisers a triumvirate of white nationalists, nomenclature which may be an understatement: Stephen Bannon, Stephen Miller and Sebastian Gorka. Gorka has been implicated in alleged ties to a Nazi-linked group in Hungary. Bannon, who formerly ran Breitbart News, which inspired the term alt-right, has a waiver allowing him to communicate with the former employer that he turned into a propagandist for the hard right. Gorka evidently a waiver, too. In an interview just before the weekend “rally”, he was at Breitbart lashing out against a New York Times reporter:

“It’s this constant, ‘Oh, it’s the white man. It’s the white supremacists. That’s the problem.’ No, it isn’t, Maggie Haberman”.

His message: We should look abroad and not be concerned about the racists intent on tearing the country apart from within.

Miller called Trump’s anti-immigration stance “magnificent”, having worked alongside Jeff Sessions to disrupt the bipartisan “Gang of Eight”‘s bill in 2013 that would have given 11 million immigrants a path to citizenship. Bannon at Breitbart was the other agent of the immigration bill’s doom, reporting that waves of Central American children were pouring across the U.S.–Mexico border, overwhelming border officials and detention centers. With these three xenophobic advisers at his side, small wonder that Trump has announced a plan to cut immigration in half.

The question is, what are three white nationalists doing in the White House on the national payroll? Put differently, if they remain, proof enough that Trump is one of them. Which is the inescapable conclusion of all the evidence and incidents that have gone before with Donald Trump that so many chose to ignore in a Faustian bargain’s belief that he would be worth it if he swept the government clean and got things done. We now need to face the shame of having elected a white supremacist as president of the United States.

Aug 26 2017 | Posted in Governance | Read More »

Repeal Failed, So Will Trump Now Sabotage Obamacare?

On his first full day in the White House, Donald Trump signed an executive order that effectively told all federal agencies to be lax in enforcing provisions of the Affordable Care Act. The order’s vigorous instruction was to let things slide
“to the maximum extent permitted by law”. Much of this has been going on ever since, most of it hidden from view.

With the Obamacare sign-up period still in progress, the newly installed Trump administration immediately pulled advertising off the air that urged people to buy insurance. In mid-February, the Internal Revenue Service said it would not be systematically rejecting returns from taxpayers who fail to disclose whether they have bought health insurance, as required by the Affordable Care Act (ACA). Failure to charge the penalty for not buying into the pool, for not “taking responsibility for oneself” as Republicans themselves advocate, deprives either the healthcare system or the insurance industry of the funds need to make the ACA work. More recently, the IRS confirmed it will continue to look the other way. This threatens to greatly weakening compliance as laxity becomes more widely known, leaving a disproportion of older, costly people more prone to illness in the insurance pool. Hospitals are alarmed because the no-longer-insured will present themselves for care with empty pockets, straining hospital finances.

Ethics tossed in the gutter, Tom Price, the head of Health and Human Services (HHS), engaged in a personal campaign disparaging the Affordable Care Act. He authored tweets and used social media to urge people to contact Congress to demand full repeal of Obamacare. The Daily Beast reported that HHS diverted taxpayer funds appropriated by law for “consumer information and outreach” and used them instead to finance a social media campaign that included videos of people complaining about their experience with the ACA — propaganda against the law that HHS is supposed to be championing and administering.

trying for a legal kill

Trump staged a celebration in the Rose Garden at the beginning of May when the House passed a bill that, according to the Congressional Budget Office, would ultimately strip 23 million of healthcare, but then he was confronted with the more recalcitrant Senate. He hectored from the sidelines with tweets such as “If Republican senators are unable to pass what they are working on now, they should immediately REPEAL, and then REPLACE at a later date!”. Alaska’s Lisa Murkowski, one of two who voted against all three Senate measures, fired back. “To just say ‘repeal and trust us — we’re going to fix it in a couple of years’ , that’s not going to provide comfort to the anxiety a lot of Alaskan families are feeling right now”.

The president was faulted by his own party for his lackadaisical support of little more than intemperate tweets. At a meeting in the White House with a number of Republicans, it was noted how little Trump had prepared himself even after discovering that “nobody” other than himself “knew that healthcare could be so complicated”. Even the Wall Street Journal cracked down. “He never tried to sell the policy to the American public, in part because he knows nothing about health care and couldn’t bother to learn”, said an editorial.

In reaction to the Senate’s failure to pass reform, Trump’s anger was on full display. He had made extravagant promises — “We’re going to have insurance for everybody “, “a [sic] healthcare that is far less expensive and far better”, “something terrific” — in total ignorance of how to deliver. He had always called the Affordable Care Act “the very, very failed and failing Obamacare law”, and a “disaster” but promised that repeal will end with “a beautiful picture.”

When three bills of varying severity failed, and with as much to lose in prestige as Trump, even Majority Leader Mitch McConnell threwn in the towel, but a few days later, Trump, irate that he didn’t win, was back, calling the Senate Republicans “total quitters”:

The strangely bewildered president then tweeted:

What filibuster? The filibuster and the 60 vote rule did not enter in. Only 51 votes were already all that was needed to pass any of the three bills voted on in the Senate. Puzzled and peeved, McConnell responded,

“It’s pretty obvious that our problem with healthcare was not the Democrats. We didn’t have 50 Republicans. There are not the votes in the Senate as I’ve said repeatedly to the president…to change the rules of the Senate”.

“I said from the beginning, let Obamacare implode, then deal”, Trump said at a law enforcement event on Long Island. With Congress moving on to tax reform, it is feared that Trump will leave Obamacare to collapse under its own weight, and do what he can to cut the supports from under it. “I’m not going to own it. We’ll let Obamacare fail, and then the Democrats are going to come to us”.

That reverts to what Trump said months ago, counseling House Speaker Paul Ryan and Secretary Price to hold off on repeal for a year and let the country watch Obamacare implode. Otherwise, “people aren’t going to see the truly devastating effects of Obamacare. If we end it, everyone’s going to say, oh, remember how great Obamacare used to be”.

who’s doing the imploding?

The most serious problem with the Affordable Care Act is that it has become unaffordable. Its exacting requirements of what an insurance plan must cover — the 10 musts [link]– make for inflexibility and costly premiums. Rather than back off some of them — maternity care for 65-year-old buyers being the one that attracted the most ridicule — yet still offer good insurance, the Ted Cruz plan wanted anything goes, permitting junk plans that would come as a nasty and ruinous surprise to those who bought them and then fell ill.

The more immediate problem is Trump’s threat that he will have the government cease paying so-called “cost-sharing reduction” subsidies to the industry. What’s that about?

For low-income customers, the ACA requires insurers to reduce the cost of their out-of-pocket health expenses such as co-payments and lower their deductible threshold so that insurance will kick in sooner. By law, insurers then expect to be reimbursed by the federal government. Without re-payment, insurers would be out of pocket several several billion dollars a year. So House Republicans, seeing a way to destroy Obamacare, sued the government in 2014, saying that Congress had never authorized the funds that Health and Human Services was disbursing. Congress sought to defund its own law.

A federal district court agreed that the payments to insurers were illegal for not having been authorized. The Obama administration appealed and the payments have continued until the case is resolved.

But President Trump could simply tell the Justice Department to drop the appeal, which would let the court decision stand and halt the payments. Without reimbursement, insurers would cease offering the discounts, insurance would be unaffordable for low-income families, and the thumb off the scale will be another tilt to skew toward customers more susceptible to illness, costlier customers who cause insurers to charge still heftier premiums or to drop out of the market — an engineered death spiral.

Which is exactly what Trump has threatened to do out of pique for not repealing Obamacare. At end July he warned insurers that he could “hurt” them by ending the payments as way to force legislators to take up repeal again after three attempts had failed. “If Obamacare is hurting people, & it is, why shouldn’t it hurt the insurance companies”. That Obamacare — which has made insurance available to millions whereas before the ACA there was no such insurance — has hurt people made as little sense as tweeting it at 5:16 AM on a Monday morning.

But the repeal and replace obsession has aggravated premiums even further. Uncertainty is the hobgoblin of the insurance industry. If they think the Trump administration will block the cost-saving subsidies , if it will not enforce the individual mandate penalizing people who do not insure themselves, if it will not urge people to buy insurance, then insurers will raise premium charges enough to protect themselves combinatorially for all these threats. Whereas if the ground rules were known , premiums could drop.

So we saw Blue Cross Blue Shield of North Carolina file for a 23% increase but said it would be 9% if Obamacare rules continued. California announced a 12.5% average increase for next year but the agency director said the increase would be twice as high for popular “silver” plans if the Trump administration blocked cost-sharing payments. That’s the biggest state talking. Idaho is one of the smallest in population,

but its insurance department said, “The proposed increases are significantly higher this year due to the potential refusal by the federal government to fund the cost-share reduction (CSR) mechanism”.

And yet spinning the lie we have Texas Republican John Cornyn saying on the Senate floor,

“The idea that premiums are going to go up next year unless something changes is a product of the failure of Obamacare. It’s nothing that this administration has done or will do that has caused that. “

The turmoil and uncertainty of repeal and replace is apparently imaginary.

insurrection

Bipartisan groups in both the House and Senate are skirting the president’s doomsday wishes realizing that allowing the Affordable Car Act to collapse would be calamitous, with millions cast adrift. Their primary mission is to craft legislation that will stabilize the insurance markets by defusing the

Realizing the consequences, Congress is pulling in the opposite direction. Republican Senator Lamar Alexander urged the president not to interrupt the payments and the health committee that he chairs would take up legislation in early September to “stabilize and strengthen the individual health insurance market”. Committee member Chris Murphy (D-CT) called it “essentially taking the keys to the American healthcare system away from the president of the United States because we’re pretty convinced that he’s going to use it [sic] to drive the healthcare system into the ground”.

A bipartisan group of some 40 House members who call themselves the Problem Solvers Caucus moved more nimbly. They have already agreed on authorizing funds for the cost-sharing payments, coupled with raising from 100 to 500 the number of employees beyond which a business is required to pay for their healthcare, and eliminating the ACA tax on medical devices. Why Obamacare added taxes to make health care more costly is baffling, and anything that moves away from businesses having to pay for employees’ insurance is commendable. It is a practice that dates from competing for workers after World War II that has never left us and you can’t find an economist who doesn’t think it a bad idea.

stayin’ alive

The Affordable Care Act handed an enormous amount of business to the insurance industry. Given stability, iIt would seem that with the actuarials of this grand experiment now in hand after several years, insurers might pile back into what should be the very lucrative market of tens of millions of customers. Here’s a hint of that from no less than an op-ed in the averse Journal:

The amount insurance companies spend on health costs relative to premium revenue, known as the medical-loss ratio, has fallen sharply in 2017, according to a recent analysis by the Kaiser Family Foundation. This suggests insurers are becoming more financially secure. The return to stable pricing means more insurers will want to enter the marketplaces, expanding competition and choice for consumers.

Out there in the marketplace, the headlines are about all the counties that no longer have an insurer — 38 of them. A Bloomberg analysis shows, however, that the all are rural and have a total of only 25,000 customers. (And aren’t these likely to be the poorer counties where it is the threat of withheld cost-sharing subsidies for low-income customers that makes the insurance companies shy away?). Contrary to that, Bloomberg says 80% of current enrollees will have two insurers to choose from.

But the stabilization proposals of the two groups in Congress are only that. Insurance companies need to set their rates for 2018 now, with uncertainty continuing in full force. They will again be forced to set rates higher still in self-defense against a possible worst case scenario.

Across the seven years that Republicans had to come up with a replacement, they seem never to have thought about what that would entail, a failure of foresight that led to reform’s hideous legislative proposals that won as little as 12% public approval. And that may now have led to a kind of surly vengeance this fall by a president who would have signed anything dropped on his desk, however malevolent, and angry that he did not win. In addition to the tactics already in play, Trump is reportedly considering reducing the subsidies that help people pay for insurance to shrink the pool by making insurance more costly. And when November comes around, there’s the question whether any funds will be spent alerting people to the annual sign-up period. People must check what’s available and the annually shifting prices — their coverage isn’t automatically renewed — so it matters greatly that they be alerted .

It wasn’t always so with Donald Trump. In a 1999 interview on “Larry King Live”, he took a very different stance. “If you can’t take care of your sick in the country, forget it, it’s all over. I mean, it’s no good. So I’m very liberal when it comes to healthcare. I believe in universal healthcare. I believe in whatever it takes to make people well and better.”

The Underside of Healthcare: Rife with Greed and Corruption

One has to look past a number of odious policies adopted by the Justice Department under Jeff Sessions — his latest is to restore police stealing from people to fund their departments — in order to find one bright spot.

And that was, a couple of weeks ago, the arrest of 412 people, across 20 states, in a Justice Department crackdown against
healthcare fraud amounting to $1.3 billion. Perpetrators had billed Medicare and Medicaid for drugs that were never disbursed, treatments and tests that were never administered, had sold prescriptions to patients for cash, and a third of them were involved with the horrific opioid scourge that is ravaging this country, taking the lives of 91 daily according to the Centers for Disease Control.

At a news conference, Acting FBI Director Andrew McCabe said that, of the 56 doctors caught up in the sweep, some had prescribed more for controlled substances in a single month than had entire hospitals. “This event again highlights the enormity of the fraud”, said Attorney General Sessions, who intends to crack down on drug crime as a priority, but that regrettably includes mandatory sentencing for minor possession that has filled prisons and ruined lives to little purpose.

The operation, largely unreported in the midst of daily Russia probe revelations, continued the work of a Medicare fraud task force established during the George W. Bush administration in 2007.

Florida, with its elderly population, is ground zero for Medicare scammers, with the Russia mafia that settled in Brighton Beach Brooklyn a close second. This catch of 412 set a record — “the largest healthcare fraud takedown operation” in history, said Sessions.

“Too many trusted medical professionals like doctors, nurses and pharmacists have chosen to violate their oaths and put greed ahead of their patients. They seem oblivious to the consequences of their greed”.

Last year, the program netted 301 people from Florida to Alaska who had bilked the government for some $900 million in charges for health treatment that never happened. Then Deputy Attorney General Sally Yates barred prosecutors from exempting persons from criminal or civil liability in cases that Justice brought against companies; immunity had until then been used to gain evidence against the businesses, so this meant a change to search warrants and raids. In the decade since its creation, the task force has nailed some 3,500 perpetrators for the fraud of $12.5 billion in phony billings. The Trump administration has put $70 million into program.

et tu doctor?

Medical professionals game the system on all fronts. The Affordable Care Act actually paid doctors to catch up with the rest of the world and convert patient records to computer databases. Yet, a federal audit found that $729 million in payments had gone out from Medicare to doctors who had claimed these “bonus” payments but in fact had done nothing to digitize.

Medicare data tells us that 1% of the 950,000 doctors and related healthcare providers accounted for 17.5% of all payouts. That was the percentage for 2013; for 2012 it was 16.6%. Some doctors specialize in very high cost patients, which accounts for part of the clustering. Others administer drugs directly, which means that the pharmaceutical companies’ outrageous prices pass through their billings. Fair enough. Others, though, have adopted the growing trend of buying expensive testing equipment for use in their own offices, which adds to their billings what previously went through separate labs or imaging outfits. But hand-in-hand with that are doctors’ tendencies to prescribe excessive tests for their patients, both to cover the cost the equipment and make more money at the expense of Medicare, Medicaid and insurers.

And then there is up-coding. Beginning in October 2014, doctor offices were required to select codes for every service performed when submitting for payment. The codes were found in a compendium called the International Classification of Diseases which had exploded to some 155,000 listings. Stung by a jellyfish this summer? The doctor or staff would have to track down code T63622A which covers the initial encounter with the jellied-beast. Up-coding is thought to be widespread where staff is encouraged to look a little further in the list to find where the jellyfish could be said to have caused complications or nausea or some follow-on ailment in order to up-code to an entry that brings in more money. Overcharging the government and insurance companies by up-coding is thought to be extensive. Regrettably, it is difficult to prove.

first, do no harm?

But some of the biggest offenses are found in otherwise, we’re told, reputable companies.

 Johnson & Johnson developed an antipsychotic drug they called Risperdal, but seeking greater profits the company aggressively marketed it for a off-label maladies such as autism and dementia. They did so undeterred by the drug’s known side effects, such as breast development for young boys and strokes for the elderly. Doctors were paid to promote the drug; a company that provided pharmaceuticals to nursing homes was paid kickbacks. J&J pleaded guilty and paid a $2 billion fine, but had sold $30 billion of the drug worldwide, doing untold harm. You can find Steven Brill’s 58,000 word investigative report, “America’s Most Admired Lawbreaker”, serialized in the Huffington Post.

 In a move to cut Medicare costs, the Bush administration began Medicare Advantage, which has since proved hugely popular among seniors. Instead of its open-ended practice of paying health providers directly for services as they occur, Medicare hands claims processing and payment to insurance companies for those seniors who sign on. Medicare pays the insurers a predetermined fee tailored to each Medicare member who chooses the Advantage alternative. But if the insurer finds that a member’s health is worse than predicted, Medicare pays extra. Or the converse: the fee paid the insurer is reduced if a member’s health profile going-in contained problems that proved to be non-existent.

But a UnitedHealth Group executive blew the whistle, asserting that his and other insurance companies have for years “data mined” members’ health records looking for conditions that could raise a patient’s “risk score” along with the fee that the score earns — irrespective of any actual health problem. This May the Justice Department sued UnitedHealth for allegedly overcharging Medicare $3 billion between 2010 and 2015.

What about the opposite — coding errors or diagnostics that proved overblown leading to excessive fees paid to the insurer? UnitedHealth had a quality control unit that identified such overpayments starting in 2011 and which caused the company to book reserves for refund to Medicare. But that good-faith program was quietly shut down when in 2014 the company experienced a shortfall in revenue. Management decided to fill the hole by zeroing out the reserves and keeping the money — $208 million for 2012, up to $180 million for 2013, $175 million for 2014.

 A 2016 inspector general report from the Health and Human Services department found that hospices often double-charge for prescription medicines and bill Medicare “far more than they should have” for a higher level of care than patients need. The report tallies the fraud to cost some $280 million a year. Much of that comes about by hospices keeping patients at their facilities for longer than necessary to earn the $720 a day fee rather than releasing them to home care at $187 a day.

 Last year the Justice Department brought the biggest healthcare fraud case in its history when it charged the owner of about 30 nursing facilities in Florida with bilking Medicare and Medicaid for over $1 billion across one and a half decades. The indictments charged that Philip Esformes and two others operated a scheme that cycled thousands of older people through the nursing facilities for treatment beyond what they needed, often dosing them with narcotics to create a need for prolonged stays to treat the addiction they had created — all with the help of doctors, pharmacists, and healthcare professionals who were paid kickbacks for helping, or hush money to keep quiet. The plot yielded millions for Esformes who indulged in the usual banalities of a “$600,000 watch, the leasing of private jets, chauffeured limousines, and periodic trips with escorts to” where, Paris? Venice? the Côte d’Azur? No. The Ritz-Carlton in Orlando.

 In New York City, Russian immigrants found a home in the Brighton Beach community of Brooklyn and chose to reward their new country with one of the highest pockets of healthcare fraud in the nation. More providers in that ZIP code have been barred from government programs than anywhere in the country other than south Florida with its retirement-age population.

In 2012 a plot was uncovered that sought to steal over a quarter of a billion dollars from insurance companies. A conspiracy of 10 doctors, 9 clinics in the city, and 105 different letter-box corporations was halfway there when shut down and prosecuted for having provided unnecessary and excessive medical treatments, physical therapy, acupuncture, pain management, psychological services, and testing such as X-rays and MRIs. Law enforcement calls it the Russian mindset. The rigid repression of the Soviet Union taught generations there that the only way to obtain anything was to outwit the system and break laws. They believe that Russia sends its recruits here with the handbook of how to game our systems. When you hear “Russian mafia”, this is where they are, stateside.

open house

Medicare and Medicaid are not helpless victims. Much of the industry’s problems can be laid at their feet. Both accept medical providers — the supposed professionals who will treat patients and submit charges for payment — without checking whether they are authentic. A probe found thousands had applied with fake addresses or had been the subject of state disciplinary actions but were accepted without scrutiny. To the good, one reason the Affordable Care Act ran to 906 pages was that it contained so much else beyond prescribing insurance plans. It called for screening that the Wall Street Journal said had kicked 34,000 providers out of the system.

The other systemic fault line, pointed out by this Journal op-ed writer says that of total claims paid by Medicare and Medicaid — $853 billion in 2015 — a stunning 10% are fraudulent owing to their practice of paying first and looking for fraud after. Claims are farmed out for processing to a “hodgepodge” of private contractors that are not asked to vet submissions; rather, they assume the good faith of medical providers. There is no one choke point through which all 4.4 million claims a day can be screened, nor the software filters and algorithms such as the highly sophisticated tools developed by credit card companies to weed out crooks.

Added together, that greed suffuses so many levels of what is supposed to be the honorable maintenance of the public weal is enough to make one ill. As said by the U.S. attorney in the Miami case we cited, “Medicare fraud has infected every facet of our healthcare system”.