The Wreck-tification of Names

Why the MAGA people love erasing all signs that anyone but them matters

Via.

Some of the work I do to keep body and soul together involves reading and explaining Medicare rules for people who run physician practices, toward the end of making it easier for them to keep track of what the government expects of them in exchange for its money. The rules, most of which are refreshed annually, range from a few hundred to thousands of pages each, and do not make for exciting reading, but I get paid a little for it and it’s a genuine and worthwhile service.

Most of the topics in the big annual physician fee schedule rules are straightforward — how much doctors will get paid for what they do, what new codes are added to the thousands they can get paid for and how the rules for performing them have changed, what performance measures they’ll be graded on and how it will affect their reimbursement, and so on.

Every once in a while something sort of new and different turns up, sometimes mandated by legislation, meant to improve how Medicare delivers care. For instance, value-based payment models and accountable care organizations were part of the reforms of the ACA era; they are supposed to deliver medical treatment more efficiently than the usual fee-for-service, and by some metrics appear to do so.

I should mention that these programs were designed to eliminate waste without taking it out of the patients’ hides, as are most such Centers for Medicare and Medicaid programs, though occasionally Congress manages to force con jobs on them like the privatization scam called Medicare Advantage.

Now, as you know the scum of the earth have taken over our government. CMS is managed by the huckster Mehmet Oz and his boss, the dangerous lunatic Robert F. Kennedy Jr. That’s very bad news, but institutions the size of Medicare are not so easy to take down; the program still has to cover its beneficiaries and pay the doctors who give treatment. Though Congress is doing its malign part by cutting the shit out of our health care budgets, at the moment Tubby’s gang can’t just steal the money and leave a card saying SO LONG SUCKERS in its place — they have to produce fee schedules, cost indices, coverage decisions, etc.

So the 2026 physician fee schedule proposed rule that just came out looks pretty much like its predecessors. But there’s a feature of it that reminds me of the some of the foul shit these guys are pulling elsewhere.

One of the concepts that has percolated through the system in recent years is health equity — the idea that some people in this great land of ours get a raw deal in general and this has a deleterious effect on their health. Since Medicare is, as I mentioned, supposed to provide care while not frittering away too much of the people’s money, CMS figured a little work on root causes might reduce the poor health conditions that lead to poor health outcomes that lead to big medical bills.

So they started looking at factors like food insecurity, poor transportation (which keeps a lot of people from the doctor in the first place), unhealthy work and living conditions and so on. The simplest fix has been assessing Medicare beneficiaries at their wellness visits for something called Social Determinants of Health, asking questions that might turn over conditions that can tell the docs what to watch out for —like incipient lung problems in a house full of smokers — and preventive and diagnostic measures that might head off expensive problems down the road.

Like I said, Medicare is hard to force big, quick changes on, and there’s not a lot of overt wrecking going on yet. CMS has a thing called ACO REACH, which stands for Accountable Care Organization Realizing Equity, Access and Community Health, and so far they aren’t fucking that one up.

But they have cut the Social Determinants of Health screening. They don’t say much about it — just “we have come to believe that the resource costs described by HCPCS code G0136 are already accounted for in existing codes, including but not limited to E/M visits.”

Now, that’s not a big-money code, and doctors, if they’re conscientious, have probably internalized the lessons of the service and will be attentive to the potential health issues for patients dealing with poverty, ghettoization, etc. Though it does suck that CMS is making that harder rather than easier.

But something else CMS is doing is starting to strip out the very mention of health equity in its programs.

For instance, they’re removing all mention of “social determinants of heath” in the Community Health Integration (CHI) code descriptor, and replacing it with “upstream drivers.” The new term, CMS says, “encompasses a wider range of root causes of the problems,” among which they include “smoking, poor nutrition, low physical activity, substance misuse.”

Maybe you won’t see it unless you’ve been staring at these things as long as I have, but it really looks to me like they’re trying to divert the implied responsibility for these negative factors from poverty and disenfranchisement to the patients themselves. (Also it has the typical clumsiness of the overworked propagandist.)

And they’ve made similar changes in other regulations. For example, in its most recent Medicare Advantage rate announcement, CMS said it planned to update the Health Equity Index (HEI) reward available to some plans and rename it “the Excellent Health Outcomes for All (EHO4all) reward because this name better captures the goal of ensuring exceptional care for all enrollees.” Uh huh.

In the latest End Stage Renal Disease rule, they propose “to remove the Facility Commitment to Health Equity reporting measure, the Screening for Social Drivers of Health reporting measure, and the Screen Positive Rate for Social Drivers of Health reporting measure from the ESRD QIP measure set.”

This may seem like a small thing. But you may have noticed small things have been a big priority with this administration. Remember how they came out guns-blazing against “DEI” from the start — which in their view meant firing women and black people from positions of authority, blaming stuff like wildfires and plane crashes on “DEI,” erasing mentions of minority achievement from federal signage and literature, etc.?

It was — has been, I should say, because they’re still doing it — obvious and stupid and obviously stupid. And it shows what they believe the power of these small changes are. In most cases the primary goal appears to be communicating to their base of bigoted freaks that they understand and share their conviction that there are too many blacks and Latinos and Muslims in prominent places, and too many women and gays with better jobs than they’ll ever have, and they’ll do what they can to stop that — and starting with symbols is easy, especially when you’ve been using social media bullshit to bamboozle those rubes in the first place.

It's also why, with the Epstein hellhound on his trail and his poll numbers tanking, Tubby went on social media to demand the Washington NFL franchise change their name back to a racist slur. And it’s why these birds are scratching words out of rules, and anything else they can get their hands on, anything that painfully reminds their people there’s anything worth paying any mind to besides privileged white man shit.