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The Chaos Party on the Hill Keeps On Chaos-ing - Even after Hamas’s attack on Israel, House Republicans are too busy fighting with themselves to get serious about the rest of the world. - link
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The Humanitarian Catastrophe in Gaza - International law obligations are nonreciprocal: one war crime doesn’t excuse another. - link
Can White House Diplomacy Help Prevent Escalation in Gaza and Beyond? - It is not a simple matter for the Biden Administration to be, on the one hand, the backstop for Israel’s looming actions in Gaza and, on the other, a voice for strategic caution and the initiator of a diplomatic track. - link
From Vox
Elon Musk wants to merge humans with AI. How many brains will be damaged along the way? -
Xinmei Liu for Vox
The brain implant company Neuralink is pushing a needlessly risky approach, former employees say.
Of all Elon Musk’s exploits — the Tesla cars, the SpaceX rockets, the Twitter takeover, the plans to colonize Mars — his secretive brain chip company Neuralink may be the most dangerous.
What is Neuralink for? In the short term, it’s for helping people with paralysis. But that’s not the whole answer.
Launched in 2016, the company revealed in 2019 that it had created flexible “threads” that can be implanted into a brain, along with a sewing-machine-like robot to do the implanting. The idea is that these threads will read signals from a paralyzed patient’s brain and transmit that data to an iPhone or computer, enabling the patient to control it with just their thoughts — no need to tap or type or swipe.
So far, Neuralink has only done testing on animals. But in May, the company announced it had won FDA approval to run its first clinical trial in humans. Now, it’s recruiting paralyzed volunteers to study whether the implant enables them to control external devices. If the technology works in humans, it could improve quality of life for millions of people. Approximately 5.4 million people are living with paralysis in the US alone.
But helping paralyzed people is not Musk’s end goal. That’s just a step on the way to achieving a much wilder long-term ambition.
That ambition, in Musk’s own words, is “to achieve a symbiosis with artificial intelligence.” His goal is to develop a technology that helps humans “merg[e] with AI” so that we won’t be “left behind” as AI becomes more sophisticated.
This fantastical vision is not the sort of thing for which the FDA greenlights human trials. But work on helping people with paralysis? That can get a warmer reception. And so it has.
But it’s important to understand that this technology comes with staggering risks. Former Neuralink employees as well as experts in the field alleged that the company pushed for an unnecessarily invasive, potentially dangerous approach to the implants that can damage the brain (and apparently has done so in animal test subjects) to advance Musk’s goal of merging with AI.
Neuralink did not respond to a request for comment.
There are also ethical risks for society at large that go beyond just Neuralink. A number of companies are developing tech that plugs into human brains, which can decode what’s going on in our minds and has the potential to erode mental privacy and supercharge authoritarian surveillance. We have to prepare ourselves for what’s coming.
Why Elon Musk wants to merge human brains with AI
Neuralink is a response to one big fear: that AI will take over the world.
This is a fear that’s increasingly widespread among AI leaders, who worry that we may create machines that are smarter than humans and that have the ability to deceive us and ultimately seize control from us.
In March, many of them, including Musk, signed an open letter calling for a six-month pause on developing AI systems more powerful than OpenAI’s GPT-4. The letter warned that “AI systems with human-competitive intelligence can pose profound risks to society and humanity” and went on to ask: “Should we develop nonhuman minds that might eventually outnumber, outsmart, obsolete and replace us? Should we risk loss of control of our civilization?”
Although Musk is not alone in warning about “civilizational risk” posed by AI systems, where he differs from others is in his plan for warding off the risk. The plan is basically: If you can’t beat ’em, join ’em.
Musk foresees a world where AI systems that can communicate information at a trillion bits per second will look down their metaphorical noses at humans, who can only communicate at 39 bits per second. To the AI systems, we’d seem useless. Unless, perhaps, we became just like them.
A big part of that, in Musk’s view, is being able to think and communicate at the speed of AI. “It’s mostly about the bandwidth, the speed of the connection between your brain and the digital version of yourself, particularly output,” he said in 2017. “Some high bandwidth interface to the brain will be something that helps achieve a symbiosis between human and machine intelligence and maybe solves the control problem and the usefulness problem.”
Fast forward a half-dozen years, and you can see that Musk is still obsessed with this notion of bandwidth — the rate at which computers can read out information from your brain. It is, in fact, the idea that drives Neuralink.
The Neuralink device is a brain implant, outfitted with 1,024 electrodes, that can pick up signals from a whole lot of neurons. The more electrodes you’ve got, the more neurons you can listen in on, and the more data you’ll get. Plus, the closer you can get to those neurons, the higher quality your data will be.
And the Neuralink device gets very close to the neurons. The company’s procedure for implanting it requires drilling a hole in the skull and penetrating the brain.
But there are less extreme ways to go about this. Other companies are proving it. Let’s break down what they’re doing — and why Musk feels the need to do something different.
There are other ways to make a brain-computer interface. Why is Neuralink choosing the most extreme one?
Earlier success in the BCI field focused not on speech, but on movement. In 2006, Matthew Nagle, a man with spinal cord paralysis, received a brain implant that allowed him to control a computer cursor. Soon Nagle was playing Pong using only his mind.
Nagle’s brain implant, developed by the research consortium BrainGate, contained a “Utah” array, a cluster of 100 spiky electrodes that is surgically embedded into the brain. That’s only around one-tenth of the electrodes in Neuralink’s device. But it still enabled a paralyzed person to move a cursor, check email, adjust the volume or channel on a TV, and control a robotic limb. Since then, others with paralysis have achieved similar feats with BCI technology.
While early technologies like the Utah array protruded awkwardly from the skull, newer BCIs are invisible to the outside observer once they’re implanted, and some are much less invasive.
Synchron’s BCI, for example, builds on stent technology that’s been around since the 1980s. A stent is a metal scaffold that you can introduce into a blood vessel; it can be safely left there for decades (and has been in many cardiac patients, keeping their arteries open). Synchron uses a catheter to send a stent up into a blood vessel in the motor cortex of the brain. Once there, the stent unfurls like a flower, and sensors on it pick up signals from neurons. This has already enabled several paralyzed people to tweet and text with their thoughts.
No open brain surgery necessary. No drilling holes in the skull.
Musk himself has said that BCIs wouldn’t necessarily require open brain surgery, in a telling five-minute video at Recode’s Code Conference in 2016. “You could go through the veins and arteries, because that provides a complete roadway to all of your neurons,” he said. “You could insert something basically into the jugular and…”
After the audience laughed nervously, he added, “It doesn’t involve chopping your skull off or anything like that.”
In Neuralink’s early years, before the company had settled on its current approach — which does involve drilling into the skull — one of its research teams allegedly looked into the tamer intravascular approach, four former Neuralink employees told me. This team explored the option of delivering a device to the brain through an artery and demonstrated that it was feasible.
But by 2019, Neuralink had rejected this option, choosing instead to go with the more invasive surgical robot that implants threads directly into the brain.
Why? If the intravascular approach can restore key functioning to paralyzed patients, and also avoids some of the safety risks that come with crossing the blood-brain barrier, such as inflammation and scar tissue buildup in the brain, why opt for something more invasive than necessary?
The company isn’t saying. But according to Hirobumi Watanabe, who led Neuralink’s intravascular research team in 2018, the main reason was the company’s obsession with maximizing bandwidth.
“The goal of Neuralink is to go for more electrodes, more bandwidth,” Watanabe said, “so that this interface can do way more than what other technologies can do.”
After all, Musk has suggested that a seamless merge with machines could enable us to do everything from enhancing our memory to uploading our minds and living forever — staples of Silicon Valley’s transhumanist fantasies. Which perhaps helps make sense of the company’s dual mission: to “create a generalized brain interface to restore autonomy to those with unmet medical needs today and unlock human potential tomorrow.”
“Neuralink is explicitly aiming at producing general-purpose neural interfaces,” the Munich-based neuroethicist Marcello Ienca told me. “To my knowledge, they are the only company that is currently planning clinical trials for implantable medical neural interfaces while making public statements about future nonmedical applications of neural implants for cognitive enhancement. To create a general-purpose technology, you need to create a seamless interface between humans and computers, enabling enhanced cognitive and sensory abilities. Achieving this vision may indeed require more invasive methods to achieve higher bandwidth and precision.”
Watanabe believes Neuralink prioritized maximizing bandwidth because that serves Musk’s goal of creating a generalized BCI that lets us merge with AI and develop all sorts of new capacities. “That’s what Elon Musk is saying, so that’s what the company has to do,” he said.
The intravascular approach didn’t seem like it could deliver as much bandwidth as the invasive approach. Staying in the blood vessels may be safer, but the downside is that you don’t have access to as many neurons. “That’s the biggest reason they did not go for this approach,” Watanabe said. “It’s rather sad.” He added that he believed Neuralink was too quick to abandon the minimally invasive approach. “We could have pushed this project forward.”
For Tom Oxley, the CEO of Synchron, this raises a big question. “The question is, does a clash emerge between the short-term goal of patient-oriented clinical health outcomes and the long-term goal of AI symbiosis?” he told me. “I think the answer is probably yes.”
“It matters what you’re designing for and if you have a patient problem in mind,” Oxley added. Synchron could theoretically build toward increasing bandwidth by miniaturizing its tech and going into deeper branches of the blood vessels; research shows this is viable. “But,” he said, “we chose a point at which we think we have enough signal to solve a problem for a patient.”
Ben Rapoport, a neurosurgeon who left Neuralink to found Precision Neuroscience, emphasized that any time you’ve got electrodes penetrating the brain, you’re doing some damage to brain tissue. And that’s unnecessary if your goal is helping paralyzed patients.
“I don’t think that tradeoff is required for the kind of neuroprosthetic function that we need to restore speech and motor function to patients with stroke and spinal cord injury,” Rapoport told me. “One of our guiding philosophies is that building a high-fidelity brain-computer interface system can be accomplished without damaging the brain.”
To prove that you don’t need Muskian invasiveness to achieve high bandwidth, Precision has designed a thin film that coats the surface of the brain with 1,024 electrodes — the same number of electrodes in Neuralink’s implant — that deliver signals similar to Neuralink’s. The film has to be inserted through a slit in the skull, but the advantage is that it sits on the brain’s surface without penetrating it. Rapoport calls this the “Goldilocks solution,” and it’s already been implanted in a handful of patients, recording their brain activity at high resolution.
“It’s key to do a very, very safe procedure that doesn’t damage the brain and that is minimally invasive in nature,” Rapoport said. “And furthermore, that as we scale up the bandwidth of the system, the risk to the patient should not increase.”
This makes sense if your most cherished ambition is to help patients improve their lives as much as possible without courting undue risk. But Musk, we know, has other ambitions.
“What Neuralink doesn’t seem to be very interested in is that while a more invasive approach might offer advantages in terms of bandwidth, it raises greater ethical and safety concerns,” Ienca told me. “At least, I haven’t heard any public statement in which they indicate how they intend to address the greater privacy, safety, and mental integrity risks generated by their approach. This is strange because according to international research ethics guidelines it wouldn’t be ethical to use a more invasive technology if the same performance can be achieved using less invasive methods.”
More invasive methods, by their nature, can do real damage to the brain — as Neuralink’s experiments on animals have shown.
Ethical concerns about Neuralink, as illustrated by its animals
Some Neuralink employees have come forward to speak on behalf of the pigs and monkeys used in the company’s experiments, saying they suffered and died at higher rates than necessary because the company was rushing and botching surgeries. Musk, they alleged, was pushing the staff to get FDA approval quickly after he’d repeatedly predicted the company would soon start human trials.
One example of a grisly error: In 2021, Neuralink implanted 25 out of 60 pigs with devices that were the wrong size. Afterward, the company killed all the affected pigs. Staff told Reuters that the mistake could have been averted if they’d had more time to prepare.
Veterinary reports indicate that Neuralink’s monkeys also suffered gruesome fates. In one monkey, a bit of the device “broke off” during implantation in the brain. The monkey scratched and yanked until part of the device was dislodged, and infections took hold. Another monkey developed bleeding in her brain, with the implant leaving parts of her cortex “tattered.” Both animals were euthanized.
Last December, the US Department of Agriculture’s Office of Inspector General launched an investigation into possible animal welfare violations at Neuralink. The company is also facing a probe from the Department of Transportation over worries that implants removed from monkeys’ brains may have been packaged and moved unsafely, potentially exposing people to pathogens.
“Past animal experiments [at Neuralink] revealed serious safety concerns stemming from the product’s invasiveness and rushed, sloppy actions by company employees,” said the Physicians Committee for Responsible Medicine, a nonprofit that opposes animal testing, in a May statement. “As such, the public should continue to be skeptical of the safety and functionality of any device produced by Neuralink.”
Nevertheless, the FDA has cleared the company to begin human trials.
“The company has provided sufficient information to support the approval of its IDE [investigational device exemption] application to begin human trials under the criteria and requirements of the IDE approval,” the FDA said in a statement to Vox, adding, “The agency’s focus for determining approval of an IDE is based on assessing the safety profile for potential subjects, ensuring risks are appropriately minimized and communicated to subjects, and ensuring the potential for benefit, including the value of the knowledge to be gained, outweighs the risk.”
What if Neuralink’s approach works too well?
Beyond what the surgeries will mean for the individuals who get recruited for Neuralink’s trials, there are ethical concerns about what BCI technology means for society more broadly. If high-bandwidth implants of the type Musk is pursuing really do allow unprecedented access to what’s happening in people’s brains, that could make dystopian possibilities more likely. Some neuroethicists argue that the potential for misuse is so great that we need revamped human rights laws to protect us before we move forward.
For one thing, our brains are the final privacy frontier. They’re the seat of our personal identity and our most intimate thoughts. If those precious three pounds of goo in our craniums aren’t ours to control, what is?
And some police departments around the world have been exploring “brain fingerprinting” technology, which analyzes automatic responses that occur in our brains when we encounter stimuli we recognize. (The idea is that this could enable police to interrogate a suspect’s brain; their brain responses would be more negative for faces or phrases they don’t recognize than for faces or phrases they do recognize.) Brain fingerprinting tech is scientifically questionable, yet India’s police have used it since 2003, Singapore’s police bought it in 2013, and the Florida state police signed a contract to use it in 2014.
Imagine a scenario where your government uses BCIs for surveillance or interrogations. The right to not self-incriminate — enshrined in the US Constitution — could become meaningless in a world where the authorities are empowered to eavesdrop on your mental state without your consent.
Experts also worry that devices like those being built by Neuralink may be vulnerable to hacking. What happens if you’re using one of them and a malicious actor intercepts the Bluetooth connection, changing the signals that go to your brain to make you more depressed, say, or more compliant?
Neuroethicists refer to that as brainjacking. “This is still hypothetical, but the possibility has been demonstrated in proof-of-concept studies,” Ienca told me in 2019. “A hack like this wouldn’t require that much technological sophistication.”
Finally, consider how your psychological continuity or fundamental sense of self could be disrupted by the imposition of a BCI — or by its removal. In one study, an epileptic woman who’d been given a BCI came to feel such a radical symbiosis with it that, she said, “It became me.” Then the company that implanted the device in her brain went bankrupt and she was forced to have it removed. She cried, saying, “I lost myself.”
To ward off the risk of a hypothetical all-powerful AI in the future, Musk wants to create a symbiosis between your brain and machines. But the symbiosis generates its own very real risks — and they are upon us now.
The Vox guide to open enrollment -
Sebastian König for Vox
Every year, picking a health plan is a frustrating guessing game. Here’s how to navigate your choices — and understand the system that built them.
It’s time for one of the most confusing, frustrating rituals of the year: health care open enrollment. Over the coming weeks and months, people across the country will consider questions that we try to avoid the other 11 months of the year: Is it better to have a high premium and a low deductible, or the other way around? How are you supposed to guess how much money to put in a flexible spending account? Does dental insurance actually, you know, do anything? Please remind me, what is “coinsurance” again?
The whole annual ordeal raises a bigger question, too: Why is all of this so complicated?
It turns out that understanding open enrollment goes a long way to helping understand the convoluted American health insurance system. The choices you face at this time of year about next year’s insurance plans are the result of quirks in the tax code and accidents of history. Nobody would build a health care system this way on purpose. But it’s the one that, for now, we’re stuck with. We hope these stories help you navigate the choices you face — while helping you understand why they exist in the first place.
— Libby Nelson
Editorial Lead: Libby Nelson | Editors: Meredith Haggerty, Alanna Okun | Reporters: Dylan Scott, Emily Stewart, Allie Volpe | Style & Standards: Tanya Pai, Caity PenzeyMoog, Kim Eggleston, Elizabeth Crane, Sarah Schweppe, Anouck Dussaud | Art Director: Paige Vickers | Illustrator: Sebastian König | Audio: A. Hall, Jonquilyn Hill, Sofi LaLonde | Audience Lead: Shira Tarlo | Managing Editors: Natalie Jennings, Nisha Chittal | Special Thanks: Blair Hickman, Andrew Losowsky, Sam Hankins, Amani Orr
The subtle privatization of Medicare -
Sebastian König for Vox
More than half of seniors will sign up for a private version of Medicare this open enrollment. What happened?
If you’re signing up for Medicare benefits this open enrollment, odds are you aren’t actually enrolling in the traditional government program that people may envision. More than half of Medicare beneficiaries are now choosing an alternative version of the program administered by private companies.
Medicare, the paragon of America’s welfare state, is undergoing a subtle but fundamental transformation from government program to public benefit provided by private companies, a shift with major implications for both patients and taxpayers. This alternative version of Medicare, known as Medicare Advantage, now covers more than half of the program’s 60 million enrollees, or about 31 million Americans — nearly double its share 10 years ago.
KFF
That explosive growth has invited fresh scrutiny. President Joe Biden and House Republicans bickered over the administration’s proposed changes to payments for the private insurers that sell Medicare Advantage plans earlier this year. Fears over Medicare’s solvency have renewed the debate about how much the plans cost the federal government. And recent investigations have added to concerns about how private companies oversee the public benefits they are supposed to provide.
If you’re choosing between traditional Medicare and an Advantage plan, here’s what you should know about the two versions of the program — how we got here, the potential drawbacks, and what could be in store for the program going forward.
What is Medicare Advantage?
Medicare has traditionally been a government-run insurance program for people over 65 and those with long-term disabilities. Medicare Advantage allows private insurers to offer their own plans that provide Medicare benefits, as well as some additional perks not available in the original program. The secret to the program’s success is simplicity. Traditional Medicare is a fragmented program: Part A covers hospital care, and Part B covers outpatient services. Patients must enroll in a separate Part D plan for prescription drug coverage that is administered by private insurers. Most people also purchase supplemental coverage, extra insurance that helps reduce their out-of-pocket costs.
Medicare Advantage, also known as Part C, combines those benefits into one insurance plan that also includes an annual limit on out-of-pocket costs, something that does not technically exist in regular Medicare.
But the benefits to patients seem to come at a cost to taxpayers. Though the health insurance industry disputes these findings, MedPAC, the independent committee tasked with overseeing Medicare on Congress’s behalf, found Medicare Advantage plans cost the federal government more money per patient than the original program would have if those same people had stuck with the traditional benefits.
Private companies are also making healthy margins on their Medicare business. A Kaiser Family Foundation analysis found that insurers were making more money per patient in Medicare Advantage than with their individual or employer-sponsored plans. Humana, which covers 5 million beneficiaries, or roughly one in five people who have elected to go with the Medicare alternative, announced this year it was dropping the rest of its portfolio to focus exclusively on the Medicare Advantage market and Medicaid managed care, a version of that government program that is similarly run by private insurers with state supervision.
Patients have clearly found something to like in what Medicare Advantage offers. The program was established in 1997 to give people a streamlined alternative, a private option less overt than more recent GOP voucher proposals.
But scholarly research and media investigations have revealed notable downsides in turning over a program that covers America’s seniors, the people who need and use the most health care, to private companies. Medicare Advantage enrollees are more likely to report trouble affording health care than people on traditional Medicare. Some of the behavior by Medicare Advantage plans, such as using AI to decide when to stop covering services for their enrollees, may be becoming more common in the private sector but is still unheard of for public programs.
The trade-off the United States seems to be making is accepting more administrative bloat and more stringent provision of benefits in exchange for a more navigable Medicare plan. The trade-off is one other countries have made as they designed universal health care programs. (A similar trend is underway in Medicaid.)
But as concern grows about Medicare facing a potential financial cliff, and evidence mounts about the costs of Medicare Advantage, the risks of the trade-off are becoming clearer. Medicare is no longer what it used to be: Once the epitome of government-run health insurance, its benefits are on the verge of being primarily funneled through private companies. Any attempts to change the program will have to wrestle with that reality.
How Medicare Advantage got so popular
Pilot programs for private insurers’ administration of Medicare date to the 1970s, but the Medicare Advantage program was created by the Balanced Budget Act of 1997, at a time when concerns about Medicare’s solvency ran high. Originally known as Medicare Choice or Part C, it was renamed Medicare Advantage in 2003, when Medicare was expanded to cover prescription drugs.
The idea was to provide patients with a simpler Medicare plan. If you have traditional Medicare, you are combining Part A, for which most people don’t pay a premium, and B, for which most people do, with a separate Part D drug plan, and potentially supplemental coverage, too. With Medicare Advantage, people can enroll in a single insurance plan that provided the full menu of benefits.
Some Medicare Advantage plans also include dental, hearing, and vision benefits, services that are not covered by the traditional program but can be critical for seniors. Medicare Advantage plans also set annual caps on out-of-pocket costs, which don’t apply in traditional Medicare. (Supplemental coverage or Medicaid instead lowers costs for most — but not all — Americans who opt for the original version of the program.)
Beneficiaries pay monthly premiums to purchase a Medicare Advantage plan; people with lower incomes qualify for subsidies. There are notable limitations in coverage. In traditional Medicare, for example, patients can go to any doctor or hospital that accepts Medicare; Medicare Advantage has more limited provider networks, and patients can be on the hook for higher costs if they are treated at an out-of-network doctor or hospital.
The federal government pays Medicare Advantage plans a flat rate for the expected cost of covering their particular customers and the insurers are required to adhere to certain rules about benefits and costs. But companies still have flexibility about how to run their plans and have a financial incentive to limit expenses. The less money they spend, the more they get to keep for themselves.
Still, customers will vote with their feet and, after slower-than-expected initial uptake, Medicare Advantage is now growing so quickly that it has become the dominant form of Medicare.
Why the movement? In a 2021 analysis published in Health Affairs, Ken Terry and David Muhlestein observed that “we’re witnessing the rapid privatization of Medicare” and offered an explanation: Medicare Advantage plans “offer beneficiaries a better deal than traditional Medicare.”
The premiums people pay for a Medicare Advantage plan can be significantly lower than the combined cost of supplemental coverage and a Part D plan — less than $50 compared to more than $200 on average, per Terry and Muhlestein — with the added benefit of having only a single insurance card. According to a 2022 Commonwealth Fund survey, the additional benefits offered by Medicare Advantage plans (such as dental or vision) and the limits on out-of-pocket costs were the most common reasons seniors gave for choosing the alternative over the original program.
In general, patients with traditional Medicare and people with Medicare Advantage say they have similar satisfaction with their benefits. On some metrics, the latter group excels; people with a Medicare Advantage plan are more likely to have a regular doctor and to say they have received preventive health care services. With a few exceptions for particular medicines, Medicare Advantage customers report fewer problems accessing their prescription drugs, too.
But people enrolled in Medicare Advantage also experience a unique set of problems compared to people who choose the original program.
The potential downsides of Medicare Advantage’s growth
Those problems, based on the available research, start with cost. A higher percentage of Medicare Advantage enrollees report having problems affording care (about 19 percent, per a 2021 KFF analysis) than those on traditional Medicare (15 percent), though people on the original program without supplemental coverage had the most problems with affordability (30 percent). (Most people on Medicare do purchase this coverage.) Black Americans and people with lower incomes were more likely to report having trouble paying for health care while enrolled in Medicare Advantage.
Other findings appear worrisome, too. Medicare Advantage patients are less likely to receive medical care at the highest-rated facilities for their particular needs, compared to people with traditional Medicare, a reflection of more restrictive provider networks. Families also reported more satisfaction with end-of-life care when using traditional Medicare.
Specific business practices by Medicare Advantage plans, and their consequences for patients, have also been called into question by investigative reporting and government inquiries over the past few years, practices that seem to run counter to Medicare’s function as an entitlement program for Americans over 65 and those with long-term disabilities.
Earlier this year, STAT reported on the increasing use of AI algorithms by these plans to determine when to cut off benefits for a customer. The lead example of their reporting was an 85-year-old woman with a broken left shoulder, whose insurer followed an algorithm that said she should be ready to leave a nursing facility and return home within 17 days.
On the 17th day of her stay, the insurer said it would no longer cover the bills for her stay, even though her doctors and nurses observed that the woman was still in extreme pain and incapable of doing basic activities, such as dressing herself or going to the bathroom. It took more than a year, and a federal judge’s order, for the patient to receive payments for the three additional weeks she needed to stay in the nursing facility. Doctors shared other stories of patients who saw benefits withdrawn at the end of their life, leaving their families to fight over the leftover bills for years after their loved one had died.
A report from federal investigators published in April 2022 found that tens of thousands of Medicare Advantage customers were denied coverage for services they should have been entitled to. A significant number of prior authorization denials (13 percent) and payment denials (19 percent) reviewed by the investigators were for services that should have been covered by the program but were not.
“Denied requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care and can burden providers,” they wrote. “Even when denials are reversed, avoidable delays and extra steps create friction in the program.”
In addition, as the New York Times reported last October, most of the largest Medicare Advantage insurers have been the subject of federal audits that found they improperly billed the program and of litigation that accused them of fraud. Taken together, the plans overbilled Medicare by between $12 billion and $25 billion in 2020, depending on the estimate.
Though Medicare Advantage was first established as a tool for reining in spending, these private plans instead seem to be perpetuating the program’s solvency crisis.
According to MedPac, since 2004, Medicare has always paid more to Medicare Advantage insurers for the cost of covering their customers than the program would have spent if the same beneficiaries had instead been enrolled in traditional Medicare. Some years, the private plans were receiving a nearly 20 percent markup compared to the original benefit structure.
MedPAC
Those high payments are drawing more attention with an insolvency crisis for Medicare Part A, which covers hospital bills, on the horizon. Part A is funded almost entirely through the program’s dedicated payroll taxes. If those benefits cost more than the government receives in Medicare payroll taxes in a given year, as can happen in an economic downturn, the difference comes out of a trust fund earmarked specifically for Part A. The Medicare trustees, who issue annual reports on the program’s finances, project that Medicare spending will begin outpacing revenue again in 2024, requiring the program to dip into the trust fund. The trust fund is projected to be fully depleted by 2028 without further policy changes.
The growth of Medicare Advantage is contributing to the financial crunch. Those plans receive funding based on the type of service provided to their customer, which means money for hospital care comes from Part A. Annual Part A payments to Medicare Advantage plans are expected to increase from about $176 billion in 2022 to $336 billion by 2030.
With revived concerns over Medicare’s solvency and evidence of excess spending in Medicare Advantage, policymakers are starting to look at making changes to the program. But that won’t be easy.
The health insurance industry will resist big changes or cuts to Medicare Advantage
Health insurers are going to fiercely defend their Medicare Advantage business against any proposed cuts, as the flap over the Biden administration’s proposed payment changes reveals. That’s because Medicare Advantage is now the industry’s most profitable line of business. United Healthcare, the nation’s largest health insurer and the largest seller of Medicare Advantage plans, has been aggressively expanding its offerings for people in the program.
Kaiser Family Foundation
That has made insurers very protective of their Medicare Advantage business. Insurers are not quite the lobbying force they were before the Affordable Care Act, but they remain highly influential and they have found allies among Republicans who have always preferred to see Medicare become more of a private operation.
Earlier this year, that alliance successfully targeted proposed payment changes by the Biden administration. As KFF analysts explained, the White House wanted to crack down on overpayments with adjustments to the complicated formula that determines when Medicare Advantage plans need to pay back the federal government for improper billing. The insurance industry painted that proposal as a cut, even though the Biden administration estimated that, when the entirety of their proposed payment plan is taken into consideration, Medicare Advantage plans would still see a 1 percent increase in payments from the federal government in 2024.
Health insurers warned of premium increases and benefit cuts, “though there is no clear evidence to suggest that,” according to the KFF analysts. They were joined by Republicans, who sought to turn the tables on Biden by accusing him of proposing Medicare cuts after the president had criticized Republican plans to cut spending for the program.
“Joe Biden is trying to gut Medicare benefits. Seniors can’t trust Democrats to protect Medicare,” one Republican campaign spokesperson told Roll Call in February. The Better Medicare Alliance, a lobbying group for Medicare Advantage plans, has started running TV ads asking seniors to petition the White House to reverse the proposed payment changes.
Though independent fact-checkers concluded that calling the Biden proposal a cut is inaccurate, the private insurers still won. The payment rates that the administration finalized in April after this brouhaha ended up being more favorable to the Medicare Advantage plans. The entire episode demonstrated Medicare Advantage’s growing political clout and previewed the fight that would likely meet any efforts to seriously alter the program.
The policy structure of Medicare Advantage is not without precedent. States have outsourced much of the administration of Medicaid to managed care plans. Countries like the Netherlands have set up health systems that use private insurers, operating under strict government oversight, to provide insurance benefits to their citizens. Giving people more choice and a more streamlined experience can have its benefits, as evidenced by the popularity of Medicare Advantage in the US.
But asking private actors, with profit motivations, to administer government benefits to which people are supposed to be entitled brings risks. People are more likely to have trouble affording health care, and their claims are more likely to be denied; that is true in places like the Netherlands, compared to other countries with more direct government administration, and that is true of Medicare Advantage when compared to the traditional Medicare program.
To date, policymakers have seemed content to let Medicare Advantage grow without much moderation. Medicare beneficiaries have been attracted to its comparative simplicity. But the costs of funding the program, amid the political environment’s shift toward more fiscal restraint, and the problems experienced by patients have put the program under the microscope.
It is difficult, at this point, to imagine the Medicare program without Medicare Advantage. The question is whether policymakers can make it more cost-effective and crack down on insurer behavior that runs counter to the program’s objectives. Recent events suggest that if they try, they will have a fight on their hands.
Update, October 16, 6 am ET: This story was originally published on March 17 and has been updated for 2023’s open enrollment process.
BCCI welcomes cricket’s inclusion in 2028 Los Angeles Olympics - Shah was the chief of ICC’s working group that dealt with the International Olympic Committee before cricket was formally inducted into the Los Angeles Olympics 2028 on Monday
Rohit Sharma on par with AB de Villiers and Viv Richards in World Cup performances | Data - Rohit’s ODI record is superlative, but his World Cup performances have been even more other-worldly — he has scored 1,195 runs in 20 matches with an average of 66.4 and strike rate of 101.96
Cricket, squash among 5 sports included in 2028 Los Angeles Olympic programme - The final choice of which sports are on the 2028 programme was voted today at the IOC session in Mumbai
Eng vs Afg | This win will put a smile on faces of my people back in Afghanistan: Rashid - Rashid said that many Afghans were struggling after the recent earthquakes
Morning Digest | One million Gazans displaced in a week, says UN; SP to contest M.P. election in alliance with Congress, and more - Here is a select list of stories to start the day
From The Hindu: National News
KCR asks people to make an informed decision before casting vote - He cautions voters that parties try to confuse, mislead them in different ways
It will be a hat-trick for BRS, says Telangana Minister Srinivas Goud - The BRS government has already introduced several programs and schemes for the welfare of people and would further do its best to secure top position among the developed States in the country, he says
I-T Department seizes cash and valuables worth ₹102 crore - Searches were conducted against against some government contractors, real estate developers, and their associates across four States
Bhadrachalam former MLA Kunja Satyavathi dies at 52 -
Israel matters more than Manipur for PM Modi: Rahul in poll-bound Mizoram - The Congress leader took part in a padayatra in Aizawl on Monday as part of the party’s Bharat Jodo Yatra programme
From BBC: Europe
Polish election: Right-wing ruling party to lose majority - exit poll - Donald Tusk’s centrist opposition has a better chance of forming a coalition if the poll is right.
France raises security level after school knife attack - France is put on its highest counter-terrorism alert, following the death of a teacher stabbed at a high school.
Germany migrants: Seven dead after vehicle crashes in Bavaria - Authorities said the driver of a “suspected smuggling vehicle” attempted to evade police before losing control.
Putin denies Russia behind Finland gas pipeline damage - Finnish officials say they cannot rule out a state actor being responsible for the rupture.
French police break up pro-Palestinian demo after ban - Tear gas is used after pro-Palestinian rallies are banned as a possible threat to public order.
From Ars Technica
Air purifiers aren’t enough to clean your home from wildfire smoke - There are ways to clean it up, however. - link
Plant-based cheese may be getting more appetizing - Can we skip the dairy and still get a cheese that doesn’t taste like plants? - link
This exoplanet might literally be the most metal planet out there - It’s likely that something stripped the outer layers off a once-rocky exoplanet. - link
CEO Bobby Kotick will leave Activision Blizzard on January 1, 2024 - Schreier: Kotick will depart after 33 years, employees are “very excited.” - link
Hydro dams are struggling to handle the world’s intensifying weather - Climate change is robbing some hydro dams of water while oversupplying others. - link
From Jokes Subreddit
God Has a Sense of Humor -
God told men they would find faithful and obedient wives in all the corners of the Earth. Then men discovered that the Earth is round, and God laughed and laughed.
Initially they didn’t talk much, but after a little time they started having family get-togethers. They became good friends for a while, even going so far as to have little decoration challenges every holiday.
Omar always pulled out all the stops come Christmas, and he seemed to enjoy it so much that, often, Chris would concede and just admire his neighbor’s over-the-top yuletide spirit.
But one year, Chris felt like upping the ante and properly competing. So instead of doing a large spread of house decor, Chris commissioned the construction of an enormous lawn ornament.
The next evening, Omar looked across the lawn and gasped–there, standing taller than a house, was a towering statue of Thor, colorfully lit and dressed like an elf.
He laughed it off as ridiculous and tacky, but to his surprise it was drawing much more attention, from strangers and neighbors alike, than his own festive manor.
More than a little disgruntled that he was no longer the talk of the HOA, he made his irritation known at dinner. Curious, his oldest daughter went over to see this titan in person.
Later that night, Chris awoke to his children’s shouts. He ran to the window and saw his beautiful Elf Thor flaming. The fire department came, but too late, as the damage was done and the magnificent creature destroyed.
Chris checked the cameras and saw what looked like a teenager approaching the statue, but before he could make out who it was, the feed cut. All footage past this point was corrupted.
Distraught, he reached out to Omar and admitted how important it was to him to win the decor war just one year, and he just wished he could find out who this kid was. Omar consoled him as best he could, but now worried he was going to have to confront his daughter….
He knocked on her door and asked her to be honest with him. She scoffed, and pulled up the house security on her laptop. Sure enough, there she was, walking back to the house only 10 minutes after leaving to see the statue. According to the CFI, the fire started over an hour later.
We may never learn the truth, but we know one thing for certain: Epps’ teen didn’t kill Hems’ elf.
A couple of lovers were in the midst of action in bed when suddenly they heard a noise at the door. The woman panicked and said to her lover, ‘My husband, my husband is here! Jump out of the window!’
Without thinking twice, the lover jumped naked out of the window and landed in some bushes. He quickly got up and joined a marathon that was happening on the street. He ran alongside the other runners, trying to blend in despite his total nudity.
In the middle of the race, another runner noticed and asked, ‘Hey, buddy, what’s your participant number?’
The lover, with a serious expression, replied, ‘Well, I don’t actually have a number today…’
The other runner, surprised, continued, ‘Why are you running barefoot then?’
The lover responded, ‘Well, I need to air out my feet; the doctor recommended staying cool because of my hypertension. If I don’t, I start feeling unwell.’
The runner was still amazed, ‘But why aren’t you wearing a shirt?’
The lover explained, ‘The breeze on my body is good for circulation. It helps with my hypertension. But don’t worry, we’ll reach the finish line together!’
The other runner finally said, ‘But what about the lack of pants or underwear?’
The lover, without losing his composure, replied, ‘Oh, that’s because I need to keep this area well-ventilated. If not, my hypertension could cause stomach problems and other inconveniences…’
The incredulous runner said, ’I see, so the condom is in case it rains, right?’"
A woman walking along the beach when she stumbled upon a Genie’s lamp. She picked it up and rubbed it, and lo-and-behold a Genie appeared. The amazed woman soon came back to her senses and asked if she got three wishes.
The Genie said, “Nope. . . due to inflation, constant downsizing, fierce global competition, and low wages in third-world countries, I can only grant you one wish. So, . . . what shall it be?”
The woman didn’t hesitate. She said, “I want peace in the Middle East. See this map? I want these countries to stop fighting with each other.”
The Genie looked at the map and exclaimed, “Good Lady! These countries have been at war for thousands of years. I’m out of shape after being in a bottle for centuries. I’m good but not THAT good! I don’t think it can be done. Make another wish.”
The woman thought for a few minutes and said, “Well, I’ve never been able to find the right man. You know, one that’s considerate and fun, likes to cook and helps with the house cleaning, is good in bed and gets along with my family, doesn’t watch sports all the time, and is faithful. That’s what I wish for — a good mate.”
The Genie let out a long sigh, shook his head and said, “Let me see that map again!”
He spots a parrot with a higher than normal price tag.
“Why is this bird so expensive?” he asked the shop owner
“Oh well, it’s a very special parrot you see” the owner replied “if you lift its right leg, it will sing a you hymn. And if you lift its left leg, it will recite a psalm”
“Wow!” the man was clearing impressed “what would it say if i lift both its legs?”
“I will fall down, you moron” the parrot said from behind.
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KFF
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MedPAC
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Kaiser Family Foundation