Ronald Steel, Critic of American Cold War Policies, Dies at 92

In essays and books. he saw the U.S. postwar era as a series of misadventures spawning unwise wars. He also wrote the definitive biography of the journalist Walter Lippmann.

https://www.nytimes.com/2023/05/08/us/ronald-steel-dead.html

By Robert D. McFadden

May 8, 2023

Ronald Steel, a historian who derided America’s Cold War foreign policies as a succession of misguided adventures and wrote a definitive biography of Walter Lippmann, the dean of 20th-century foreign policy realism, died on Sunday in Washington. He was 92.

The death, at a nursing home, was caused by complications of dementia, said his longtime physician and friend, Michael Newman.

A bookish, small-town boy from Illinois who became a soldier, wanderer, translator, diplomat, journalist, author and professor, Mr. Steel since the early 1960s had been one of the nation’s most prolific critics of America’s master plans for navigating a perilous, changing world. He often examined his subjects through prisms of biography and magazine profiles of those who shaped foreign policies.

In the high-stakes game of global chess, Mr. Steel infuriated presidents, secretaries of state and other national leaders with astringent yet sparkling essays that filled seven books and hundreds of commentaries in The New Republic, The New York Times and The New York Review of Books. He also taught at Yale, Princeton, the University of Southern California and other colleges.

His best-known book, “Walter Lippmann and the American Century” (1980), was the story of the most influential journalist of his age, who founded The New Republic, was a confidant of presidents from Woodrow Wilson to Lyndon Johnson and reached millions with syndicated columns that argued for a foreign policy of pragmatism rather than a global crusade against Communism.

One of the most discussed political biographies of its time and a best seller, the Lippmann biography won the National Book Critics Circle Award for general nonfiction, Columbia University’s Bancroft Prize and The Los Angeles Times Book Prize for History, and was a finalist for the National Book Award and the 1981 Pulitzer Prize for biography. Its critical reception was divided, largely along political lines.

Basically, Mr. Steel insisted that Washington’s strategy for dealing with Moscow — the postwar “containment doctrine” that defined American policy toward the Soviet Union for four decades — had been wasteful and deluded, spawning costly wars in Korea and Vietnam and obsessions with national security that left Americans no more secure, prosperous or free than the rest of the world.

The American diplomat in Moscow George F. Kennan articulated that doctrine in the journal Foreign Affairs in 1947, proposing “a policy of firm containment, designed to confront the Russians with unalterable counterforce at every point where they show signs of encroaching upon the interests of a peaceful and stable world.” President Harry S. Truman made it official as “the Truman Doctrine.”

“The watershed event of the Truman presidency was certainly the Korean War,” Mr. Steel wrote in a retrospective commentary in The New Republic in 1992. “It transformed the vague rhetoric of the Truman Doctrine into a blueprint for interventions against communism that set the precedent in Vietnam and the proxy wars of the Reagan era.”

In his first book, “The End of the Alliance” (1964), Mr. Steel argued that the North Atlantic Treaty Organization was already obsolete five years after its birth in 1949 and that it should be dissolved as a way of stepping back from what he regarded as the growing prospect of a nuclear war between the United States and the Soviet Union.

In “Pax Americana” (1967), he warned of an obsession with “the Communist menace.” The title came from a 1963 speech by President John F. Kennedy urging Americans to reflect on their Cold War attitudes, asking: “What kind of peace do we seek? Not a Pax Americana enforced on the world by American weapons of war.” The historian Henry Steele Commager called the book “the most persuasive critique of American foreign policy over the last 20 years.”

As many Americans debated and eventually soured on the Vietnam War, some scholars began to question whether the United States had become a counterrevolutionary power committed to the defense of a global status quo. Mr. Steel extrapolated on that point in his review, in The New York Times, of Neil Sheehan’s book “A Bright Shining Lie: John Paul Vann and America in Vietnam” (198

“Vietnam is the graveyard of an image we held of ourselves: America as the defender of the oppressed,” Mr. Steel wrote. “In Vietnam we were confronted with ourselves as an imperial power, fighting not for democracy but to demonstrate that Communist-led ‘wars of national liberation’ were not the wave of the future.”

Even after the Soviet Union collapsed in 1991, Mr. Steel contended, in “Temptations of a Superpower” (1995), that American foreign policy remained incoherent because, he wrote, it was based on activism by presidents promoting their own political interests and causes, and because America still viewed itself as a global policeman, determined to guarantee stability around the world.

Lauding the book, Alan Tonelson, a fellow of the Economic Policy Institute at the time, wrote in The New York Times Book Review: “In a political climate where the labeling of all dissenting foreign policy voices as ‘isolationist’ is praised in the news media as responsible leadership, Mr. Steel’s essay is a rare example of clarity, wisdom and intellectual integrity.”

Mr. Steel, in “New Perspectives Quarterly” in 1997, sounded yet another warning.

“The disappearance of the rival superpower, which was also the ideological challenger, has not resulted in any contraction of American global goals,” he wrote. “The ‘free world’ has now been extended to virtually the entire world as anti-communism, in American geopolitical strategy, has been replaced by the amorphous concept of global order.”

Ronald Lewis Sklut was born on March 25, 1931, in Morris, Ill., the older of two sons of Abe and Beatrice (Mink) Sklut. His father, a Jewish immigrant from Russia, owned a clothing store. Ronald and his brother, Bruce, attended public schools in Morris, 30 miles southwest of Chicago.

“I did a lot of reading, but mostly in secret so that I wouldn’t be considered bookish by the regular guys,” Mr. Steel wrote in an autobiographical sketch for the reference book World Authors after adopting the nom de plume Ronald Steel in about 1960. “I was also aware, as one of the few Jews in a very small farm town, that this was considered an extremely odd and exotic thing to be.”

He graduated from Northwestern University in 1953 with a Bachelor of Arts degree in political science and English and earned a master’s degree in political economy from Harvard in 1955. Fluent in French when drafted by the Army, he was posted to a general’s staff in Paris. After his discharge, he joined the Foreign Service and was a vice consul in Hamburg in 1957-58. Returning to New York, he became the editor of Scholastic Magazines from 1959 to 1962.

Later in the 1960s he lived in Paris and London, translated French books on European politics and business affairs, and wrote his first two books. He also wrote articles on American foreign policy for The New York Review of Books, many of them collected in an ironically titled volume, “Imperialists and Other Heroes: A Chronicle of the American Empire” (1971).

Mr. Steel began working on his biography of Mr. Lippmann in the early 1970s. It took nearly a decade, a task complicated, he said, by Mr. Lippmann’s reluctance to reveal “personal” aspects of his life.

Anthony Lewis, in The Times, called the Lippmann book “candid and balanced,” adding, “Steel does not flinch from unpleasant facts or critical judgments.”

But Joseph Epstein, the former editor of The American Scholar, called it “a catalog of revisionist presuppositions, assumptions and notions” and “scarcely more than a checklist of Walter Lippmann’s opinions.”

In “Partial Payments: Essays on Writers and Their Lives” (1989), Mr. Epstein took Mr. Steel to task as a writer and historian. “In foreign policy, Steel’s point of view is that of a revisionist, which means he believes that the past 40 years or so in American foreign policy have been a period of imperialist intention,” with the United States seeking “world hegemony.”

He added: “Steel views the Cold War as more the fault of the United States than of the Soviet Union, and in his own journalism he has shown a great impatience with what he construes to be the screen of moral babble, paranoia and simple hypocrisy behind which American policy has operated.”

Mr. Steel’s last book, “In Love With Night: The American Romance with Robert Kennedy” (2000), attacked what he called myths about the senator that arose after his assassination in Los Angeles during the 1968 presidential primaries — that “had he lived and become president, he would have quickly ended the war in Vietnam, brought Black and white Americans together, alleviated poverty and discrimination, and achieved a more just and humane society.” Mr. Steel said “there is little, beyond hope and need, to lead us to believe” that R.F.K. would have achieved such goals.

Starting in the early 1970s, Mr. Steel taught at Yale, the University of Texas, Wellesley College, Rutgers University, U.C.L.A., Dartmouth, George Washington University, the Woodrow Wilson International Center for Scholars in Washington, the University of Paris, the American Academy in Berlin and Princeton. He taught at U.S.C. from 1986 until he retired in 2008.

He is survived by his brother, Bruce Sklut. Mr. Steel’s cognitive impairment progressed in 2016, and since then he had lived at the Sunrise nursing home Sunrise on Connecticut Avenue in Washi

 

He had kept an apartment in Washington for years, and rarely visited his hometown in Illinois.

“I lived in New York and Paris and London, and in a dozen other places across the globe that for a time I called home,” Mr. Steel told World Authors. “All those places shaped me in one way or another. But somewhere along the way I also stopped trying to escape from the small town. Confinement, I’ve come to think, lies more in the head than in the place.”

 

 

 

Corporate Giants Buy Up Primary Care Practices at Rapid Pace - NYT

 

Corporate Giants Buy Up Primary Care Practices at Rapid Pace

Large health insurers and other companies are especially keen on doctors’ groups that care for patients in private Medicare plans.

https://www.nytimes.com/2023/05/08/health/primary-care-doctors-consolidation.html?smid=nytcore-ios-share&referringSource=articleShare

By Reed Abelson

May 8, 2023Updated 10:57 a.m. ET

It’s no surprise that the shortage of primary care doctors — who are critically important to the health of Americans — is getting worse.

They practice in one of medicine’s lowest paid, least glamorous fields. Most are overworked, seeing as many as 30 people a day; figuring out when a sore throat is a strep infection, or managing a patient’s chronic diabetes.

So why are multibillion-dollar corporations, particularly giant health insurers, gobbling up primary care practices? CVS Health, with its sprawling pharmacy business and ownership of the major insurer Aetna, paid roughly $11 billion to buy Oak Street Health, a fast-growing chain of primary care centers that employs doctors in 21 states. And Amazon’s bold purchase of One Medical, another large doctors’ group, for nearly $4 billion, is another such move.

The appeal is simple: Despite their lowly status, primary care doctors oversee vast numbers of patients, who bring business and profits to a hospital system, a health insurer or a pharmacy outfit eyeing expansion.

And there’s an added lure: The growing privatization of Medicare, the federal health insurance program for older Americans, means that more than half its 60 million beneficiaries have signed up for policies with private insurers under the Medicare Advantage program. The federal government is now paying those insurers $400 billion a year.

“That’s the big pot of money everyone is aiming at,” said Erin C. Fuse Brown, director of the Center for Law, Health & Society at Georgia State University, and an author of a New England Journal of Medicine article about corporate investment in primary care. “It’s a one-stop shop for all your health care dollars,” she said.

Many doctors say they are becoming mere employees. “We’ve seen this loss of autonomy,” said Dr. Dan Moore, who recently decided to start his own practice in Henrico, Va., to have more say in caring for his patients. “You don’t become a physician to spend an average of seven minutes with a patient,” he said.

The absorption of doctor practices is part of a vast, accelerating consolidation of medical care, leaving patients in the hands of a shrinking number of giant companies or hospital groups. Many already were the patients’ insurers and controlled the distribution of medicines through ownership of drugstore chains or pharmacy benefit managers. But now, nearly seven of 10 of all doctors are either employed by a hospital or a corporation, according to a recent analysis from the Physicians Advocacy Institute.

The companies say these new arrangements will bring better, more coordinated care for patients, but some experts warn the consolidation will lead to higher prices and systems driven by the quest for profits, not patients’ welfare.

Insurers say their purchase of medical practices is a step toward what is called value-based care, with the insurer and doctor paid a flat fee to care for an individual patient. The fixed payment acts as a financial incentive to keep patients healthy, provide more access to early care and reduce hospital admissions and expensive visits to specialists.

The companies say they favor the fixed fees over the existing system that pays doctors and hospitals for every test and treatment, encouraging doctors to order too many procedures.

Under Medicare Advantage, doctors often share profits with insurers if the doctors take on the financial risk of a patient’s care, earning more if they can save on treatment. Instead of receiving a few hundred dollars for an office visit, primary care doctors can be paid as much as $14,000 a year to manage a single patient.

But experts warn these major acquisitions threaten the personal nature of the doctor-patient relationship, especially if the parent company has the authority to dictate limits on services from the first office visit to extended hospital stays. Once enrolled, these new customers can be steered toward chains of related businesses, like a CVS drugstore or Amazon’s online pharmacy.

UnitedHealth Group is a sprawling example of consolidated services. It owns the major insurer that has nearly 50 million customers in the United States and oversees its ever-expanding subsidiary, Optum, which has bought up networks of doctors and medical sites. Optum can send patients from one of its roughly 70,000 doctors to one of its urgent care or surgery centers.

Senator Elizabeth Warren, Democrat of Massachusetts, is urging the Federal Trade Commission to take a closer look at some of these large deals, which regulators have so far not blocked on antitrust grounds. “I fear that the acquisition of thousands of independent providers by a few massive health care mega-conglomerates could reduce competition on a local or national basis, hurting patients and increasing health care costs,” she wrote to regulators in March.

This consolidation of medical care may also run afoul of state laws that prohibit what is called corporate medicine. Such statutes prevent a company that employs doctors from interfering with patient treatment.

And experts warn of the potential harm to patients, when corporate management seeks to control costs through byzantine systems requiring prior authorization to receive care.

For example, Kaiser Permanente, the giant nonprofit health plan that also owns physician groups, settled a malpractice case for nearly $2.9 million last year with the family of Ken Flach, a former tennis player who contracted pneumonia and died from sepsis after a Kaiser nurse and doctor would not send him for an in-person visit or to the emergency room, despite the urgent pleading of his wife. Kaiser said medical decisions are made by its providers in consultation with their patients and said its “deepest sympathy remains with the Flach family.”

Doctors also chafe at oversight that does not benefit patients. “They are trying to run it like a business, but it’s not a business,” said Dr. Beth Kozak, an internal medicine doctor in Grand Rapids, Mich.

Her doctors’ group has teamed up with Agilon Health, an investor-owned company, to work with Medicare Advantage plans. Dr. Kozak said she has to work longer hours, not to provide better care, but to supply additional diagnoses for patients, which increases federal reimbursements under the Medicare Advantage program. “It’s not because I’m giving better patient care,” she said. “It’s all tied to the billing.”

The corporate consumption of medical care keeps growing. Walgreens Boots Alliance, one of the largest U.S. pharmacy operations, spent $5 billion for a majority stake in VillageMD, a primary care group, and teamed with Cigna to buy another medical group for nearly $9 billion. And short of an outright purchase, UnitedHealth is partnering with Walmart to offer care to older patients.

In promoting the benefits of buying Oak Street clinics to investors, Karen S. Lynch, the chief executive of CVS Health, said primary care doctors lower medical costs. “Primary care drives patient engagement and positive clinical outcomes,” she said.

Many of these companies are building chains of clinics. On a recent tour of an Oak Street clinic in Bushwick, one of 16 centers opened since October 2020 in New York City, patients were typically seen from 8 a.m. to 5 p.m., with a nurse available after hours to field questions.

Ann Greiner, the chief executive of the Primary Care Collaborative, a nonprofit group, defended the recent forays by private companies into this field of health care, saying they are infusing practices with sorely needed funds and may improve access to care for people in underserved areas.

“The salaries of the folks in those arrangements are higher,” she said. “They are providing more comprehensive care in many of those arrangements. They are providing more tech and more team-based care. That’s all investment.”

But these deals also risk shifting the balance from quality treatment to profits, she said.

In recent years, some have invoked the laws banning corporate medicine to challenge these large-scale private operations. Envision Healthcare, a private equity-backed company that employs emergency room doctors, is being sued in California by a unit of the American Academy of Emergency Medicine, a professional group that supports independent practices, accusing it of violating that state’s provisions.

“Envision exercises profound and pervasive direct and indirect control and/or influence over physicians practice of medicine,” according to the lawsuit. The suit maintains that Envision controls the doctors’ billing and establishes medical protocols.

While Envision would not comment on the litigation, it said it “follows an operating structure that is common across the health care sector and widely used by nonprofit, privately held and public groups as well as hospitals and insurers.”

The big insurers find doctors’ groups particularly attractive, although many have reported sizable losses. The acquisition of Oak Street, which has lost more than $1 billion over the last three years, could help CVS’s Medicare Advantage plans improve their quality or “star” ratings and increase payments for one of its plans.

Even small numbers of patients can translate into significant revenue. One Medical, the company Amazon owns, is best known for sleek clinics. The company scooped up a practice specializing in Medicare Advantage. Only about 5 percent of One Medical’s 836,000 members are enrolled in that federal program, but roughly half of its revenue comes from that tiny slice of patients, according to its 2022 financial statements.

Regulators are already flagging questionable methods employed by some practices. In November 2021, Oak Street disclosed that the Justice Department was investigating sales ploys like free trips to its clinics and payment of insurance agents for referrals. One doctor at a center described recruiting patients with “gift cards, swag and goody bags,” according to a shareholder lawsuit against Oak Street.

The lawsuit detailed concerns that doctors were inflating the payments from the federal government by overstating how sick their patients were.

Oak Street says it has not been accused of any wrongdoing by the Justice Department and says the lawsuit is “without merit.”

These private Medicare Advantage plans have been heavily criticized for racking up enormous profits by inflating costs and exaggerating patients’ illnesses to charge the government more than they should.

Under new rules, the Biden administration would eliminate some of the most problematic, overused diagnoses, and doctors and insurers could earn less.

But other pathways to profit also explain why corporations covet these deals. Unlike the caps on insurers’ moneymaking, where a Medicare Advantage insurer has to spend at least 85 cents of every dollar on patient care, there are no limits to how much profit these doctor practices and pharmacy chains can make.

It may be too soon to determine whether consolidated care will improve patients’ health. “So far, when you look across the industry, the record of these acquisitions has been mixed,” said Dr. Sachin H. Jain, the chief executive of SCAN Group, a nonprofit based in Long Beach, Calif., that offers Medicare Advantage plans.

And the investments may not halt the rapid disappearance of the doctor still sought by so many people for ordinary care, including a recent report showing fewer medical school graduates going into the field.

“We’re dealing with incredible levels of burnout within the profession,” said Dr. Max Cohen, who practices near Portland, Ore. Since the pandemic, his low-income patients have become much sicker, he said, with the level of illness “through the roof.”

Reed Abelson covers the business of health care, focusing on health insurance and how financial incentives affect the delivery of medical care. She has been a reporter for The Times since 1995. @ReedAbelson 

 

 

 

 

 

 

 

 

 

 

 

What’s Behind the GOP’s War Against Democracy? -The Hartman Report

 And are rightwing billionaires who want more, more, more money willing to make common cause with bigots, fascists, and wannabee killers to get it?

Thom Hartmann

Apr 17, 2023

 

https://open.substack.com/pub/thomhartmann/p/whats-behind-the-gops-war-against?r=3qu3t&utm_campaign=post&utm_medium=email

Louise and I just finished watching the Netflix short series Transatlantic, and it prompted us to consider what happens when a rightwing social movement takes over a country, as we’re currently experiencing in the US with more than a third of our states openly embracing fascism.

Transatlantic is a gripping drama about a group of Jewish refugees — including Hannah Arendt and Marc Chagall — who are trapped in Marseilles trying to flee the Nazis as they sweep across France in late 1940. Complicating their flight, the American envoy and the head of the local French police are both in agreement with the Nazis that the Jewish refugees are “degenerates” and “animals” who should appropriately end up in the Nazi camps.

The parallels to today’s America are startling. The Republican rhetoric about the queer and Black communities — and, often, about Jews (usually coded as “George Soros”) — is startlingly similar to that of the Nazis and the Vichy French about Jews. Donald Trump, for example, is openly calling Alvin Bragg an “animal.”

But how do things get this far? How and why did it happen in Germany, and how and why is it happening here today?

After Hitler’s failed beer hall putsch, he was legally banned from public speaking and mass rallies. In 1930, however, German media mogul Alfred Hugenberg — a rightwinger who owned two of the largest national newspapers and had considerable influence over radio — joined forces with Hitler and relentlessly promoted him, much like the Murdoch media empire and billionaire-owned rightwing radio helped bring Trump to power in 2016.

While politically independent, German President Paul von Hindenburg’s sympathies lay with the conservatives and monarchists. Like Reagan’s GOP, Hindenburg’s coalition favored Germany’s morbidly rich (Hindenburg’s father was an aristocrat) and industry, but was always just short of achieving total power over the German state.

Hitler, on the other hand, didn’t seem to care much at first about Germany’s aristocrats; he led a populist evangelical movement dedicated to “purifying” Germany of the “filth” of Jews, homosexuals, Gypsies, and socialists. While Hindenburg and the German conservative movement looked down on Hitler and his followers as ignoble rabble rousers, they were more than enthusiastic about getting their votes.

As German industrialist Fritz Thyssen writes in his apologetic book I Paid Hitler, he pressured German President von Hindenburg to appoint Hitler as chancellor, and then lobbied the Association of German Industrialists, that country’s and era’s version of the US Chamber of Commerce, to donate 3 million Reichsmarks to the Nazi Party for the 1932 election.

While Thyssen did it primarily because he wanted tax cuts for morbidly rich people like himself and government contracts for his company, his efforts combined with Hugenberg’s media empire brought Hitler and his bigots to power.

Hitler’s sales pitch to the German people was grounded in the idea that average German working people were victims and Hitler was their champion.

He claimed Jews, homosexuals, and socialists had “stabbed Germany in the back” by participating in negotiations for the Treaty of Versailles that imposed punitive conditions on the country, producing widespread poverty and an economic crisis.

If the German people were victims, Hitler told them, the villains were German minorities, promoting degeneracy like jazz and swing music, tolerance of homosexuality and transgender people, and the “international Jewish conspiracy.”

Once the Nazis took power they banned books, outlawed drag shows and homosexuality, changed school curricula to remove mention of their atrocities in WWI, and rewrote election laws so they’d never again lose an election.

The transformation of Germany was swift. Former German Nazis I knew well in the 1980s when I lived in that country often commented to me on how “a party of bullies” threatened violence and intimidated people to the point that the average person gave up resisting or even joined along for fear of ending up a victim themselves.

Thus, a minority party that never took more than a third of the national vote before seizing power began a process that inevitably led to the death of 73 million human beings.

Once you build your party’s political base on hate and fear it’s pretty much impossible to one day say, “You know, those Jews and Blacks and queer people we were vilifying aren’t really such bad people after all.”

This is all echoed in the crisis today facing both the GOP and the Democratic Party’s opposition to it.

As former Labor Secretary Robert Reich recently wrote:

“My friends, the Republican Party is no longer committed to democracy. It is rapidly becoming the American fascist party.”

Rightwing American billionaires, parroting Fritz Thyssen, have spent the past decade pouring money into Republican-aligned groups working to change school textbooks, ban library books, outlaw healthcare for queer people, criminalize trans participation in civil society, and make it harder for college students and Black people to vote.

Like Thyssen, most probably aren’t all that bigoted themselves: their primary motivation is lowering their own taxes and increasing their companies’ government purchases and subsidies.

But to get there they must have Republicans in power, and the GOP’s base — while they don’t much care about billionaire’s taxes or corporate deregulation — are fervent bigots.

Democrats, meanwhile, face the same crisis the Social Democrats did in Germany in the 1930s.

They believe in the free speech and free flow of political ideas associated with democracy, so are wary of using government power to squelch the rise of the current fascist movement within the GOP. Yet they see the direction things are moving and are frequently — but impotently — calling it out.

Holding bullies to account for their crimes and their intimidation tactics is really and truly difficult, as the German Social Democrats discovered in 1933 and Manhattan DA Alvin Bragg is realizing today. Typically the only thing that stops bullies is to punch them in the face, which can reduce one to their level.

There are signs that a few of the billionaires funding the modern neofascist wing of the GOP’s rise to power are having second thoughts, much as Fritz Thyssen ultimately did in Germany.

Billionaire DeSantis backer Thomas Peterffy (the second richest man in Florida at $26 billion) told The Financial Times last week:

“I have put myself on hold.  Because of (DeSantis’) stance on abortion and book banning ... myself, and a bunch of friends, are holding our powder dry.”

So far, Peterffy is the outlier. The billionaire-funded movement to pass anti-voting, anti-trans, anti-Black history, anti-gay marriage, anti-abortion, and anti-public school legislation and policy is roaring down the track, as is the billionaire-owned media campaign to promote fascism.

And since five corrupt Republicans on the Supreme Court legalized political bribery with Citizens United, the deck remains stacked in their favor.

There is no Democratic equivalent to Fox “News,” 1500 rightwing radio stations, hundreds of subsidized rightwing podcasts and media sites, The Wall Street Journal, ALEC, Heritage Foundation, Musk’s rightwing reinvention of Twitter, Facebook’s GOP-leaning algorithms, or the hundreds of other state and national policy operations and think tanks.

The American people, however, seem to be waking up even in the face of this onslaught of billionaire-owned and -funded media and political infrastructure.

The velocity with which Republican governors are leaving ERIC so they can quietly purge people from their voting rolls (now that five corrupt Republicans on the Supreme Court legalized that in 2018) and passing over 400 new make-it-harder-to-vote laws shows how concerned they are about this trend.

So, to the question about what’s really behind the war Republicans are waging against American democracy, the answer is simple: rightwing billionaires who want more, more, more money and are willing to make common cause with bigots, fascists, and wannabee killers to get it.

Given how far we are down this road to fascism — and how the GOP’s fascist faction is being supported by both American billionaires and outsiders like Orbán, Putin, and Xi — the 2024 election may well be the equivalent of the November, 1932 German elections: a make-or-break moment for American democracy.

Thank you for reading The Hartmann Report. This post is public so feel free to share it.

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B4’ It’s Too Late: The Socialist Left’s Role in Fighting Autocracy - Convergence/Portside

 B4—the Broad Front Opposing the Right—can’t be about the status quo. While it must be aimed at defeating all attacks on our democratic rights, its thrust must be to expand democracy and shift US domestic and foreign policy.

https://portside.org/2023-01-07/b4-its-too-late-socialist-lefts-role-fighting-autocracy?utm_source=portside-general&utm_medium=email

Breach of the US Capitol, January 6, 2021, photo by Brett Davis, licensed CC BY-NC 2.0

I found myself watching the Netflix series Babylon Berlin over the last several weeks.  Netflix has three seasons of this German-made look at 1929 Weimar Germany.  Though technically a mystery revolving around a German police detective, this is a story of the collapse of the Weimar Republic and the growing strength of the Communists as well as various right-wing currents within the republic, including but not limited to Nazism.  As such, it is chilling and cannot but force a US viewer to reflect upon the growth of right-wing populism and right-wing authoritarianism in the US.

It was within this broader political and media context of the growth of right-wing authoritarianism that I read Pro-Democracy Organizing against Autocracy in the United States (PDOA for short).  This is an amazing, comprehensive, and sobering look at what needs to be considered and undertaken in the face of virulent right-wing authoritarian mass movement.

By way of preface, it is important to be clear that the right-wing populist/authoritarian movement that has become energized since 2009 did not appear out of nowhere.  The history of the US as a racial settler-colonial project laid very firm foundations for the periodic rise of nefarious movements of the political Right, movements that are regularly racist, sexist, xenophobic and irrationalist.  The current incarnation of right-wing populism aims to create a future for the US based on a reconfigured US, something akin to the pre-1912 country, if not being a 21^st century version of the Confederate States of America. A neoliberal right-wing combined with a far-right semi-fascist tendency has resulted in the development of what can be understood as a “neo-Confederate” political bloc.  This is a complicated and contradictory alliance that shares the objective of establishing a semi-apartheid system in the US along with the suppression of basic democratic rights up to and including the possibility of gutting and redoing the Constitution.

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Pro-Democracy Organizing Against Autocracy in the United States takes, as its starting point, the possibility of the successful capture of government by right-wing authoritarian forces.  It does not treat this as inevitable, nor does it suggest that all is hopeless should such a scenario come into existence.  But it does argue that in order to prevent the success of right-wing authoritarians and undermine a right-wing authoritarian hegemony, there must be a new practice introduced by progressive forces.  In sum this includes:

• Building and maintaining a large-scale, multi-racial, cross-class pro-democratic united front
• Protecting, holding and building local community power through alternative institutions
• Building pressure to create splits and defections within the Right
• Preventing, deterring, and strengthening resistance to state security force and/or paramilitary violence.

The paper also suggests specific steps in this direction that include information networks, education and training efforts, international outreach and, interestingly, development of conflict resolution mechanisms for handling contradictions within the broad front.

Rather than reiterate the excellent points raised in the paper, points with which I am largely in agreement, I believe it necessary to focus on the particular role and vision that a socialist Left can advance in our current situation and in building resistance to right-wing authoritarianism.

Clarity on the nature of the enemy

PDOA is unapologetic in identifying the principal enemy at this juncture being what I described earlier as the “neo-Confederate bloc.”  To say that it is the principal enemy does not mean that it is the only enemy.  It means, however, that strategy must focus, first and foremost, on taking down the principal enemy and that all else is secondary.

There should be nothing surprising in this assertion.  Whether in war or politics, one must first ascertain who or what is the main enemy and then figure out the steps—and alliances—necessary in order to bring them down.  A failure to attain that clarity can mean a dispersal of resources and, ultimately, failure. 

Starting here is critical since there are many forces on the US Left that refuse to identify the neo-Confederate bloc as the principal enemy.  They remain obsessed with taking down centrist Democrats or believing that these two opponents are equally dangerous, as if the centrist Democrats are trying to destroy abortion, voting rights and the recognition that the Earth is round.  If one cannot identify the principal opponent, the approach elaborated in PDOA is futile.

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The need for “B4”—before it is too late

As PDOA suggests as its first point, there is a need for what I would term a “Broad Front Opposing the Right,” i.e., “B4.”  The authors suggest that efforts towards such a front need to be started immediately through a series of summits.  Let’s step back for a moment, however.

Using the term “broad front” aims to convey both the scale and scope of this project, but also to avoid unnecessary discussions that disarm the Left over whether one is building a “united front” or a “popular front.”  In the context of 21^st century US, what is being proposed is a “broad” front that has a focus on overcoming and smashing the far-Right, i.e., demolishing the neo-Confederate bloc.  PDOA is correct in saying that this must be multi-racial/multi-national and cross-class.  It cannot be an alignment of the Left alone nor can it be limited to those who are in total agreement with a left/progressive agenda.

B4 must first of all be defensive in that it is actively opposing the thrust from the far-Right.  It is aiming to put the breaks on the neo-Confederate offensive.  Thus, the question that must be asked by those trying to bring such a front into existence—which is hopefully the socialist Left and our immediate allies—revolves around identifying who that should include.  To answer that, there must be a broad mapping of liberal, progressive and left forces across the US.

There is a prior step, however.  The socialist Left and left/progressive forces need to have a convening to ensure that there exists a critical mass of organizations and individuals committed to this path.  Building B4 will involve considerable political, organizational and diplomatic work.  This core will need to take responsibility for moving the B4 process, though a broader left/progressive configuration will be necessary in order to actually convene a full-blown B4 process.

A socialist Left core that has an analysis of the larger national picture, will need to undertake the diplomatic work involved in initiating the sorts of convenings that PDOA suggests.

B4 needs to be convened by organizations and individuals with a real base

There are too many left and progressive convenings that have involved noted individuals and interested people who have no base.  Even a large gathering of people is next to irrelevant if they lack a base.  Thus, there is a need for groups such as the Working Families Party, Progressive Democrats of America, as well as a host of state-based and locally based left/progressive groups that have a real mass base to play the leading role in a convening.  The socialist Left, through its work in such groups, must fight for a united front orientation and against sectarianism and small-group mentality.

Principles that unite and the need to reject purity

The Right is far better at united fronts/broad fronts than the Left.  They make it easy for people to join their mass movements and set very few preconditions.  Their assumption, proven over and again, is that they will win people to their overall framework through the course of their work in one of their fronts.

The Left, on the other hand, insists on raising the bar for entry into our various projects.  We tend to set purity tests of various sorts and identify why we cannot unite, rather than determining what steps are necessary in order to unite.

B4 necessitates principles of unity that distinguish it from both the neo-Confederate bloc and the Democratic National Committee.  This does not mean that it should take a sectarian stand towards the Democratic National Committee.  Rather, it must be far broader in content but also in its strategic and tactical approaches.  More about that below.

Establish clear strategic objectives

It is one thing to convene a gathering (no matter how difficult); it is another to establish clarity on strategic direction.  B4 needs to have a set of strategic objectives in terms of what it seeks to accomplish at the national, state and local levels over the next 10 years.  Those objectives, we should note, should not be restricted to electoral cycles.  They should aim at winning broad left/progressive power at the national, state and local levels through defeating the Right and presenting a program that breaks with the status quo.

This last point cannot be overemphasized.  B4 cannot be about the status quo.  While it must be aimed at defeating all attacks on our democratic rights, its thrust must be to expand democracy; a program of consistent democracy.  As such B4 must aim to shift US domestic and foreign policies, combatting the Right domestically and globally.

Encourage splits within the Right

One of the most insightful and courageous points raised in PDOA is the need to encourage defections from the neo-Confederate bloc.  For many leftists, such an idea is an anathema to our general approach.  Yet, in order to defeat our opponents, we must ascertain means of provoking splits within their ranks and demoralizing component parts of their blocs.

To use a strange analogy, I was once engaged in protecting a meeting from the intrusion of provocateurs.  The provocateurs showed up and said—openly—that if they had to bust into the meeting, they needed to attack my colleague first and not me.  That was a brilliant move aimed at destabilizing the alliance with my colleague and trying to get me to fight less.

B4 must employ a similar approach.  That means that there will be Republicans, independents, etc., with whom we have no strategic unity, but with whom we may have tactical unity in opposing the far-Right.  Under those circumstances, we must find means for united action or, at a minimum, aim to neutralize them.

And B4 does what?

Left and progressive forces regularly form coalitions and then nothing happens!  Usually this is connected with lack of strategy and, specifically, the inability to prioritize.  B4 will need to coordinate activities among its constituents; provide on-going information as well as counter the propaganda of the Right; and engage in various campaigns (electoral and non-electoral).  This work includes:

• Building up electoral fronts on a state-wide basis
• Mounting electoral assaults or counterassaults against the Right
• Overturning efforts being undertaken by the Right to convene a Constitutional Convention
• Utilizing ballot initiatives in order to destabilize the Right, consolidate progressive opinion, and build base areas in Republican-dominated states
• Constructing social media strategy focused on mobilization and information provision
• Organizing mass mobilizations that go beyond ‘Saturday in the park’ rallies.  Specifically, countering mass mobilizations carried out by the Right; building defensive mass actions when the far-Right makes is appearance
• Building legal assistance networks when progressive and liberal forces come under attack, e.g., when rightwing elected leaders move against so-called Antifa elements and BLM elements
• Building various levels of self-defense.

Conflict-resolution within B4 and resolving “contradictions among the people”

So many progressive coalition efforts are undermined by rumor-mongering, miscommunications, and the heightening of contradictions until differences result in splits.  We have little successful experience in internal mediation with an aim of resolving differences.

While some differences are actually splitting differences, a new approach can be introduced in order to sustain and build B4. Among the understandings and practices in this approach:

• Allegations do not equal the truth.  When allegations are offered, whether regarding personal behavior or a political stance, B4 needs to have a conflict-resolution policy and mechanism to surface  issues and address them directly.  Allegations must be accompanied by facts rather than remain as feelings and opinions.
• Presume good will.  Despite what will inevitably be major differences, B4 participants should start from an assumption of positive intent.  Internal differences should not be treated as equivalent to differences with our opponents.
• There should be protocols or agreements on acceptable and unacceptable behavior within B4.
• Organizations within B4 should not act unilaterally on any matters that the broader front is attempting to resolve—or act upon—except and insofar as B4 is incapable of making a decision.
• B4 should anticipate that contradictions and problems will emerge along racial, ethnic, gender and religious lines.  These should be handled according to the prior approach.  Individuals and organizations should be encouraged to hold back on jumping to conclusions.  And, where errors have been committed, a process of rectification should be put into place in order to correct the underlying problem.

Is the socialist Left up to the challenge?

Therein lies the question.  The socialist Left vacillates between grandiosity and myopia.  We often cannot conceive of winning because winning necessitates broad alliances with forces with whom we are frequently at odds.  Additionally, we quickly elevate every difference to one of principle rather than deciding what issues/matters can and must be resolved at any given moment and what can be placed on hold.

If we can agree that B4 is essential, and if we can agree on the overall approach offered by PDOA, then we can proceed with all deliberate speed, in organizing to weather the coming storm and build a countercurrent advancing consistent democracy.

Bill Fletcher Jr. is a longtime trade unionist, writer and speaker. He was also a president of TransAfrica Forum, chairperson of the board of directors of Advocates for Minor Leaguers, and co-coordinator of the Campaign to End the Moroccan Occupation of Western Sahara. He is a member of the International Work Team of Liberation Road. He has written and edited several books, including Solidarity Divided: The Crisis in Organized Labor and A New Path Toward Social Justice (with Fernando Gapasin, University of California Press, 2009) and the murder mystery novel The Man Who Fell From the Sky (Hardball Press, 2018) and its forthcoming sequel.

 Convergence is a magazine for radical insights. We work with organizers and activists on the frontlines of today’s most pressing struggles to produce articles, videos and podcasts that sharpen our collective practice, lift up stories from the grassroots, and promote strategic debate. Our goal is to create the shared strategy needed to change our society and the world. Our community of readers, viewers, and content producers are united in our purpose: winning multi-racial democracy and a radically democratic economy.

 

Illustration by Lisa Larson-Walker/ProPublica Health Care How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them

  by Patrick Rucker, Maya Miller and David Armstrong March 25, 5 a.m. EDT

https://www.propublica.org/article/cigna-pxdx-medical-health-insurance-rejection-claims

Internal documents and former company executives reveal how Cigna doctors reject patients’ claims without opening their files. “We literally click and submit,” one former company doctor said.

Co-published with The Capitol Forum

Series: Uncovered

How the Insurance Industry Denies Coverage to Patients

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

Do you have experiences with health insurance denials? Please get in touch.

When a stubborn pain in Nick van Terheyden’s bones would not subside, his doctor had a hunch what was wrong.

Without enough vitamin D in the blood, the body will pull that vital nutrient from the bones. Left untreated, a vitamin D deficiency can lead to osteoporosis.

A blood test in the fall of 2021 confirmed the doctor’s diagnosis, and van Terheyden expected his company’s insurance plan, managed by Cigna, to cover the cost of the bloodwork. Instead, Cigna sent van Terheyden a letter explaining that it would not pay for the $350 test because it was not “medically necessary.”

The letter was signed by one of Cigna’s medical directors, a doctor employed by the company to review insurance claims.

Something about the denial letter did not sit well with van Terheyden, a 58-year-old Maryland resident. “This was a clinical decision being second-guessed by someone with no knowledge of me,” said van Terheyden, a physician himself and a specialist who had worked in emergency care in the United Kingdom.

 

Nick van Terheyden Credit: Jared Soares for ProPublica

The vague wording made van Terheyden suspect that Dr. Cheryl Dopke, the medical director who signed it, had not taken much care with his case.

Van Terheyden was right to be suspicious. His claim was just one of roughly 60,000 that Dopke denied in a single month last year, according to internal Cigna records reviewed by ProPublica and The Capitol Forum.

The rejection of van Terheyden’s claim was typical for Cigna, one of the country’s largest insurers. The company has built a system that allows its doctors to instantly reject a claim on medical grounds without opening the patient file, leaving people with unexpected bills, according to corporate documents and interviews with former Cigna officials. Over a period of two months last year, Cigna doctors denied over 300,000 requests for payments using this method, spending an average of 1.2 seconds on each case, the documents show. The company has reported it covers or administers health care plans for 18 million people.

In the 17 hours and 20 minutes and 30 seconds you’ve been on this page, Cigna’s doctors could have denied 74916 claims, according to company documents.

Before health insurers reject claims for medical reasons, company doctors must review them, according to insurance laws and regulations in many states. Medical directors are expected to examine patient records, review coverage policies and use their expertise to decide whether to approve or deny claims, regulators said. This process helps avoid unfair denials.

But the Cigna review system that blocked van Terheyden’s claim bypasses those steps. Medical directors do not see any patient records or put their medical judgment to use, said former company employees familiar with the system. Instead, a computer does the work. A Cigna algorithm flags mismatches between diagnoses and what the company considers acceptable tests and procedures for those ailments. Company doctors then sign off on the denials in batches, according to interviews with former employees who spoke on condition of anonymity.

“We literally click and submit,” one former Cigna doctor said. “It takes all of 10 seconds to do 50 at a time.”

Not all claims are processed through this review system. For those that are, it is unclear how many are approved and how many are funneled to doctors for automatic denial.

Insurance experts questioned Cigna’s review system.

Patients expect insurers to treat them fairly and meaningfully review each claim, said Dave Jones, California’s former insurance commissioner. Under California regulations, insurers must consider patient claims using a “thorough, fair and objective investigation.”

“It’s hard to imagine that spending only seconds to review medical records complies with the California law,” said Jones. “At a minimum, I believe it warrants an investigation.”

Do You Have Insights Into Health Insurance Denials? Help Us Report on the System.

Insurers deny tens of millions of claims every year. ProPublica is investigating why claims are denied, what the consequences are for patients and how the appeal process really works.

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Within Cigna, some executives questioned whether rendering such speedy denials satisfied the law, according to one former executive who spoke on condition of anonymity because he still works with insurers.

“We thought it might fall into a legal gray zone,” said the former Cigna official, who helped conceive the program. “We sent the idea to legal, and they sent it back saying it was OK.”

Cigna adopted its review system more than a decade ago, but insurance executives say similar systems have existed in various forms throughout the industry.

In a written response, Cigna said the reporting by ProPublica and The Capitol Forum was “biased and incomplete.”

Cigna said its review system was created to “accelerate payment of claims for certain routine screenings,” Cigna wrote. “This allows us to automatically approve claims when they are submitted with correct diagnosis codes.”

When asked if its review process, known as PXDX, lets Cigna doctors reject claims without examining them, the company said that description was “incorrect.” It repeatedly declined to answer further questions or provide additional details. (ProPublica employees’ health insurance is provided by Cigna.)

Former Cigna doctors confirmed that the review system was used to quickly reject claims. An internal corporate spreadsheet, viewed by the news organizations, lists names of Cigna’s medical directors and the number of cases each handled in a column headlined “PxDx.” The former doctors said the figures represent total denials. Cigna did not respond to detailed questions about the numbers.

Cigna's explanation that its review system was designed to approve claims didn’t make sense to one former company executive. “They were paying all these claims before. Then they weren’t,” said Ron Howrigon, who now runs a company that helps private doctors in disputes with insurance companies. “You’re talking about a system built to deny claims.”

Cigna emphasized that its system does not prevent a patient from receiving care — it only decides when the insurer won’t pay. “Reviews occur after the service has been provided to the patient and does not result in any denials of care,” the statement said.

"Our company is committed to improving health outcomes, driving value for our clients and customers, and supporting our team of highly-skilled Medical Directors,” the company said.

PXDX

Cigna’s review system was developed more than a decade ago by a former pediatrician.

After leaving his practice, Dr. Alan Muney spent the next several decades advising insurers and private equity firms on how to wring savings out of health plans.

In 2010, Muney was managing health insurance for companies owned by Blackstone, the private equity firm, when Cigna tapped him to help spot savings in its operation, he said.

Insurers have wide authority to reject claims for care, but processing those denials can cost a few hundred dollars each, former executives said. Typically, claims are entered into the insurance system, screened by a nurse and reviewed by a medical director.

For lower-dollar claims, it was cheaper for Cigna to simply pay the bill, Muney said.

“They don’t want to spend money to review a whole bunch of stuff that costs more to review than it does to just pay for it,” Muney said.

Muney and his team had solved the problem once before. At UnitedHealthcare, where Muney was an executive, he said his group built a similar system to let its doctors quickly deny claims in bulk.

In response to questions, UnitedHealthcare said it uses technology that allows it to make “fast, efficient and streamlined coverage decisions based on members benefit plans and clinical criteria in compliance with state and federal laws.” The company did not directly address whether it uses a system similar to Cigna.

At Cigna, Muney and his team created a list of tests and procedures approved for use with certain illnesses. The system would automatically turn down payment for a treatment that didn’t match one of the conditions on the list. Denials were then sent to medical directors, who would reject these claims with no review of the patient file.

Cigna eventually designated the list “PXDX” — corporate shorthand for procedure-to-diagnosis. The list saved money in two ways. It allowed Cigna to begin turning down claims that it had once paid. And it made it cheaper to turn down claims, because the company’s doctors never had to open a file or conduct any in-depth review. They simply denied the claims in bulk with an electronic signature.

“The PXDX stuff is not reviewed by a doc or nurse or anything like that,” Muney said.

The review system was designed to prevent claims for care that Cigna considered unneeded or even harmful to the patient, Muney said. The policy simply allowed Cigna to cheaply identify claims that it had a right to deny.

Muney said that it would be an “administrative hassle” to require company doctors to manually review each claim rejection. And it would mean hiring many more medical directors.

“That adds administrative expense to medicine,” he said. “It’s not efficient.”

But two former Cigna doctors, who did not want to be identified by name for fear of breaking confidentiality agreements with Cigna, said the system was unfair to patients. They said the claims automatically routed for denial lacked such basic information as race and gender.

“It was very frustrating,” one doctor said.

Some state regulators questioned Cigna’s PXDX system.

In Maryland, where van Terheyden lives, state insurance officials said the PXDX system as described by a reporter raises “some red flags.”

The state’s law regulating group health plans purchased by employers requires that insurance company doctors be objective and flexible when they sit down to evaluate each case.

If medical directors are “truly rubber-stamping the output of the matching software without any additional review, it would be difficult for the medical director to comply with these requirements,” the Maryland Insurance Administration wrote in response to questions.

Medicare and Medicaid have a system that automatically prevents improper payment of claims that are wrongly coded. It does not reject payment on medical grounds.

Within the world of private insurance, Muney is certain that the PXDX formula has boosted the corporate bottom line. “It has undoubtedly saved billions of dollars,” he said.

Insurers benefit from the savings, but everyone stands to gain when health care costs are lowered and unneeded care is denied, he said.

Speedy Reviews

Cigna carefully tracks how many patient claims its medical directors handle each month. Twelve times a year, medical directors receive a scorecard in the form of a spreadsheet that shows just how fast they have cleared PXDX cases.

Dopke, the doctor who turned down van Terheyden, rejected 121,000 claims in the first two months of 2022, according to the scorecard.

 

Van Terheyden’s denial letter from Cigna Credit: highlights and redactions added by ProPublica

Dr. Richard Capek, another Cigna medical director, handled more than 80,000 instant denials in the same time span, the spreadsheet showed.

Dr. Paul Rossi has been a medical director at Cigna for over 30 years. Early last year, the physician denied more than 63,000 PXDX claims in two months.

Rossi, Dopke and Capek did not respond to attempts to contact them.

Howrigon, the former Cigna executive, said that although he was not involved in developing PXDX, he can understand the economics behind it.

“Put yourself in the shoes of the insurer,” Howrigon said. “Why not just deny them all and see which ones come back on appeal? From a cost perspective, it makes sense.”

Cigna knows that many patients will pay such bills rather than deal with the hassle of appealing a rejection, according to Howrigon and other former employees of the company. The PXDX list is focused on tests and treatments that typically cost a few hundred dollars each, said former Cigna employees.

“Insurers are very good at knowing when they can deny a claim and patients will grumble but still write a check,” Howrigon said.

Muney and other former Cigna executives emphasized that the PXDX system does leave room for the patient and their doctor to appeal a medical director’s decision to deny a claim.

But Cigna does not expect many appeals. In one corporate document, Cigna estimated that only 5% of people would appeal a denial resulting from a PXDX review.

“A Negative Customer Experience”

In 2014, Cigna considered adding a new procedure to the PXDX list to be flagged for automatic denials.

Autonomic nervous system testing can help tell if an ailing patient is suffering from nerve damage caused by diabetes or a variety of autoimmune diseases. It’s not a very involved procedure — taking about an hour — and it costs a few hundred dollars per test.

The test is versatile and noninvasive, requiring no needles. The patient goes through a handful of checks of heart rate, sweat response, equilibrium and other basic body functions.

At the time, Cigna was paying for every claim for the nerve test without bothering to look at the patient file, according to a corporate presentation. Cigna officials were weighing the cost and benefits of adding the procedure to the list. “What is happening now?” the presentation asked. “Pay for all conditions without review.”

By adding the nerve test to the PXDX list, Cigna officials estimated, the insurer would turn down more than 17,800 claims a year that it had once covered. It would pay for the test for certain conditions, but deny payment for others.

These denials would “create a negative customer experience” and a “potential for increased out of pocket costs," the company presentation acknowledged.

But they would save roughly $2.4 million a year in medical costs, the presentation said.

Cigna added the test to the list.

“It’s Not Good Medicine”

By the time van Terheyden received his first denial notice from Cigna early last year, he had some answers about his diagnosis. The blood test that Cigna had deemed “not medically necessary” had confirmed a vitamin D deficiency. His doctor had been right, and recommended supplements to boost van Terheyden’s vitamin level.

 

Van Terheyden Credit: Jared Soares for ProPublica

Still, van Terheyden kept pushing his appeal with Cigna in a process that grew more baffling. First, a different Cigna doctor reviewed the case and stood by the original denial. The blood test was unnecessary, Cigna insisted, because van Terheyden had never before been found to lack sufficient vitamin D.

“Records did not show you had a previously documented Vitamin D deficiency,” stated a denial letter issued by Cigna in April. How was van Terheyden supposed to document a vitamin D deficiency without a test? The letter was signed by a Cigna medical director named Barry Brenner.

Brenner did not respond to requests for comment.

Then, as allowed by his plan, van Terheyden took Cigna’s rejection to an external review by an independent reviewer.

In late June — seven months after the blood test — an outside doctor not working for Cigna reviewed van Terheyden’s medical record and determined the test was justified.

UnitedHealthcare Tried to Deny Coverage to a Chronically Ill Patient. He Fought Back, Exposing the Insurer’s Inner Workings.

The blood test in question “confirms the diagnosis of Vit-D deficiency,” read the report from MCMC, a company that provides independent medical reviews. Cigna eventually paid van Terheyden’s bill. “This patient is at risk of bone fracture without proper supplementations,” MCMC’s reviewer wrote. “Testing was medically necessary and appropriate.”

Van Terheyden had known nothing about the vagaries of the PXDX denial system before he received the $350 bill. But he did sense that very few patients pushed as hard as he had done in his appeals.

As a physician, van Terheyden said, he’s dumbfounded by the company’s policies.

“It’s not good medicine. It’s not caring for patients. You end up asking yourself: Why would they do this if their ultimate goal is to care for the patient?” he said.

“Intellectually, I can understand it. As a physician, I can’t. To me, it feels wrong.”

In the 17 hours and 20 minutes and 30 seconds you’ve been on this page, Cigna’s doctors could have denied 74916 claims, according to company documents.

Doris Burke contributed research.

Clarification, March 27, 2023: This article was updated to clarify that a response from the Maryland Insurance Administration referred to medical directors in general.