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posted by martyb on Saturday August 20 2016, @08:19PM   Printer-friendly
from the dancing-elephants-are-hard-on-the-ants dept.

Submitted via IRC for crutchy with a story from Ars Technica.

Following on the heels of UnitedHealth group and Humana, insurance giant Aetna plans to "dramatically slash its participation in the public insurance marketplace" — "claims losses alone spurred decision, but there are clear links to merger."

[...] In 2017, Aetna will only offer insurance policies in 242 counties scattered across four states—that’s a nearly 70-percent decrease from its 2016 offerings in 778 counties across 15 states.

[...] In April, Mark Bertolini, the chairman and chief executive of Aetna, told investors that the insurance giant anticipated losses and could weather them, even calling participation in the marketplaces during the rocky first years “a good investment.” And in a July 5 letter (PDF) to the Department of Justice, obtained by the Huffington Post by a Freedom of Information Act request, Bertolini explicitly threatened that Aetna would back out of the marketplace if the department tried to block its planned $37 billion merger with Humana.

[Continues...]

From the July 5 letter:

[...] We have been operating on the public exchanges since the beginning of 2014 at a substantial loss. And although we have been working to improve our operations over the last 2 ½ years, we are challenged to get to break even this year and it will be some time before we recoup our investment (including a return on invested capital in the exchange business). As we add new territories, given the additional startup costs of each new territory, we will incur additional losses. Our ability to withstand these losses is dependent on our achieving anticipated synergies in the Humana acquisition.

[...] We have consistently indicated to our investors that the public exchanges and the ACA small group business remain risks to our achieving our financial projections since these markets face significant hurdles as outlined above. Should the deal be blocked the challenges will be exacerbated as we are facing significant unrecoverable costs including carrying costs of the debt required to finance the deal [...] and significant unrecoverable transaction and integration costs. We currently plan to cover the above costs, as well as invest in capabilities, improve benefits, pass savings through to members and customers and expand our business using [...] synergies we expect to obtain through the transaction. If we are unable to close the transaction we will need to recover those costs plus a breakup fee and [...] litigation expenses if the DOJ sues to enjoin the transaction.

[...] We currently plan, as part of our strategy following the acquisition, to expand from 15 states in 2016 to 20 states in 2017. However, if we are in the midst of litigation over the Humana transaction, given the risks described above, we will not be able to expand to the five additional states. In addition, we would also withdraw from at least five additional states where generating a market return would take too long for us to justify, given the costs associated with a potential break- up of the transaction. In other words, instead of expanding to 20 states next year, we would reduce our presence to no more than 10 states. We also would not be in a position to provide assistance to failing cooperative exchanges as we did in Iowa recently.

The Ars Technica article continues:

Sixteen days after the letter was penned, the DOJ moved to block the merger. In announcing the department’s decision to file suit, Attorney General Loretta Lynch said it “would leave much of the multitrillion health insurance industry in the hands of just three mammoth companies, restricting competition in key markets.”

In interviews this week, Bertolini has brushed off the tie between marketplace participation and the merger deal, reiterating that the cuts were all based on finances. “As a strong supporter of public exchanges as a means to meet the needs of the uninsured, we regret having to make this decision,” Bertolini told The New York Times . He noted that the company faced “a second-quarter pretax loss of $200 million and total pretax losses of more than $430 million since January 2014 in our individual products.”

But Obama allies weren't buying the explanation. In a Facebook post, Senator Elizabeth Warren (D-Mass.), noted that Aetna has the right to fight the DOJ on the merger. But, she said, “the health of the American people should not be used as bargaining chips to force the government to bend to one giant company’s will.”

[To start the discussion: What if, in those exchanges where no insurer chose to provide coverage, people would be permitted to enroll in Medicare? -Ed.]


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  • (Score: 1, Insightful) by Justin Case on Saturday August 20 2016, @08:48PM

    by Justin Case (4239) on Saturday August 20 2016, @08:48PM (#390704) Journal

    Obamacare was designed to fail, to clear the way for totalitarianism.

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  • (Score: 0) by Anonymous Coward on Saturday August 20 2016, @09:02PM

    by Anonymous Coward on Saturday August 20 2016, @09:02PM (#390711)

    > Obamacare was designed to fail, to clear the way for totalitarianism.

    Lolwut?

    • (Score: 3, Interesting) by Anonymous Coward on Sunday August 21 2016, @02:14AM

      by Anonymous Coward on Sunday August 21 2016, @02:14AM (#390831)

      Cloward–Piven strategy [wikipedia.org]. I can see how you hadn't heard about it - it's only been discussed for fifty years.

      "a political strategy outlined in 1966 by American sociologists and political activists Richard Cloward and Frances Fox Piven that called for overloading the U.S. public welfare system in order to precipitate a crisis"

      • (Score: 0) by Anonymous Coward on Sunday August 21 2016, @05:08PM

        by Anonymous Coward on Sunday August 21 2016, @05:08PM (#391093)

        Yes, there' the famous line from Chomsky:

        That's the standard technique of privatization: defund, make sure things don't work, people get angry, you hand it over to private capital.

        What's not being mentioned is the opposite side of the coin: Regulate an industry to death, make sure things don't work, people get angry, you nationalise it.

        Cloward and Piven were certainly right about one thing (if only by implication), in that nursing along a broken system does not make it better, but that overloading it and breaking it can actually provide an opportunity for improvement.

  • (Score: 2) by opinionated_science on Saturday August 20 2016, @09:05PM

    by opinionated_science (4031) on Saturday August 20 2016, @09:05PM (#390712)

    At any one time the medical insurance industry is represented by 2 groups of people:

    a) payers
    b) withdrawers

    The insurance companies make a "business" by denying coverage to b) while still collecting from a). Of course b) a).

    The problem is the pool of folks in a) discounts those 26 yrs old (assuming they had parental coverage), and includes a load of people that were previously denied covered now making up b).

    The fact of the matter is that unless the mechanism of medicine is made not-for-profit, this insanity will prevail. There was an excellent NPR series looking at this a few years ago, that explained the lack of incentive for *any* of the parties to lower costs. i.e. the clamiants, the insurers and the clinicians.

    Finally, the fact that some members of congress think they are immortal doesn't help - EVERY human ever born will need medical care - it's just a matter of when...

    • (Score: 0) by Anonymous Coward on Saturday August 20 2016, @09:17PM

      by Anonymous Coward on Saturday August 20 2016, @09:17PM (#390716)

      First Rule of Acquisition. Once you have their money, you never give it back.

    • (Score: 4, Insightful) by Justin Case on Saturday August 20 2016, @09:18PM

      by Justin Case (4239) on Saturday August 20 2016, @09:18PM (#390717) Journal

      At any one time the grocery industry is represented by 2 groups of people:

      a) sellers
      b) buyers

      The grocery companies make a "business" and try to make a profit by charging as much as they can to b). However if they get too crazy b) will just go to another a) and everybody knows it, which keeps things more or less in check.

      Imagine if you had grocery "insurance". All of b) would want steak for dinner every night.

      Imagine if you had "single payer groceries". All of b) would want steak for dinner every night.

      Oh and before you bring "need" into it, remember that everybody "needs" food too. Insurance and freebies is the problem, not the profit motive. Profit-making businesses have done a fine job of making food available to almost everyone but the very poorest, and we have charities to help with that.

      • (Score: 1, Insightful) by Anonymous Coward on Saturday August 20 2016, @09:26PM

        by Anonymous Coward on Saturday August 20 2016, @09:26PM (#390723)

        Bad analogy, groceries are all priced before you buy.
        Healthcare is fundamentally different, you get the bill (often inflated, then later negotiated down to something more reasonable) after the service.

        • (Score: 2) by Justin Case on Saturday August 20 2016, @09:36PM

          by Justin Case (4239) on Saturday August 20 2016, @09:36PM (#390725) Journal

          And that problem could never possibly be fixed, right?

          • (Score: 0) by Anonymous Coward on Saturday August 20 2016, @09:56PM

            by Anonymous Coward on Saturday August 20 2016, @09:56PM (#390735)

            > And that problem could never possibly be fixed, right?

            Right. No foolproof way to know before surgery if it will go smoothly or if there will be complications (post infection, internal bleeding, etc, etc.) Just one of many reasons that healthcare can't be priced like groceries.

            Another way your analogy is f'ed up is that we all want food. Many of us actually _like_ food so much that we pay extra to go out to eat and enjoy the atmosphere and special food. On the contrary, no one that I know wants to deal with doctors or the healthcare system any more than absolutely necessary. I'm healthy, get a checkup every 10 years or so to have a baseline. I've paid for insurance for many years (a bit grudgingly) as just that, insurance in case I'm in an accident. Or if all of a sudden I contract something that current medicine can actually treat.

            • (Score: 1) by khallow on Saturday August 20 2016, @10:26PM

              by khallow (3766) Subscriber Badge on Saturday August 20 2016, @10:26PM (#390753) Journal

              No foolproof way to know before surgery if it will go smoothly or if there will be complications (post infection, internal bleeding, etc, etc.) Just one of many reasons that healthcare can't be priced like groceries.

              No foolproof way for the grocery store to know if their customers will get injured just due to walking into a store due to a condition of negligence set up by an employee. But of course, markets work in conditions far outside that of the grocery store so we're not even considering stuff that is relevant to a health care market.

            • (Score: 1, Informative) by Anonymous Coward on Sunday August 21 2016, @02:18AM

              by Anonymous Coward on Sunday August 21 2016, @02:18AM (#390833)

              http://surgerycenterok.com/pricing/ [surgerycenterok.com]

              Care to try again?

              The only reason the US medical monopolies can get away with the massive rip-off scam they've been running is with the help of government regulation aka guns.

      • (Score: 4, Informative) by Capt. Obvious on Saturday August 20 2016, @10:13PM

        by Capt. Obvious (6089) on Saturday August 20 2016, @10:13PM (#390742)

        Profit-making businesses have done a fine job of making food available to almost everyone but the very poorest

        Except when it hasn't. Or rather, regulated profit-making businesses have done a fine job.

        The tragedy of the commons is named after an agricultural issue. The government manages grazeland out west. Subsidized farmers ensure the food supply. the FDA ensures we're not being poisoned. Etc, etc. etc.

      • (Score: 2) by krishnoid on Saturday August 20 2016, @11:45PM

        by krishnoid (1156) on Saturday August 20 2016, @11:45PM (#390786)

        PETA would like a word with you.

      • (Score: 0) by Anonymous Coward on Sunday August 21 2016, @12:36AM

        by Anonymous Coward on Sunday August 21 2016, @12:36AM (#390803)

        Not even close unless you can go years and years without buying food or just buying $200.00 of food a year. And then maybe through no fault of your own, maybe by accident, you have a $250,000.00 food bill. It's about insurance, not about food! Duh.

      • (Score: 5, Insightful) by sjames on Sunday August 21 2016, @01:15AM

        by sjames (2882) on Sunday August 21 2016, @01:15AM (#390813) Journal

        Groceries are pretty much a constant. Medical care is mostly in the form of catastrophically expensive surprises.

        There is time to look for the best prices on groceries. You can mix and match, some things here others there. There are many largely interchangeable brands for each item and most people understand food well enough to choose. Finally, you can stock up when prices are good and use that stock when prices are too high.

        In medicine, you may not even be conscious when the choice is made for you.Even if you are, you probably can't wait a few days until TPA goes on sale at Kroger. It's doubtful you'll be able to transfer to a cheaper hospital. (Assuming you can figure out what hospital that might be when nobody publishes prices).

        It's a perfect storm for a massive failed market. That's why so few countries try to cram it into a market system.

        • (Score: 0) by Anonymous Coward on Sunday August 21 2016, @02:51AM

          by Anonymous Coward on Sunday August 21 2016, @02:51AM (#390846)

          Medical care is mostly in the form of catastrophically expensive surprises

          So why does the health insurance forcibly sold to USians cover routine care?

          • (Score: 2) by sjames on Sunday August 21 2016, @05:52AM

            by sjames (2882) on Sunday August 21 2016, @05:52AM (#390916) Journal

            Mostly as a hangover from the thinking in the '70s that HMOs would provide routine care to catch problems so they would be merely disastrously expensive over a a lifetime rather than catastrophically expensive. The conspirist in me suggests it's because otherwise the healthcare industry might get a bit of unwanted (by them) market feedback about prices.

            I sometimes wonder if they would also like for us to forget that the most common issues (cold, flu, minor sprains, cuts scrapes, etc) can be resolved with simple proven home remedies at least as well as a doctor can handle them.

          • (Score: 2, Informative) by Anonymous Coward on Sunday August 21 2016, @04:09PM

            by Anonymous Coward on Sunday August 21 2016, @04:09PM (#391061)

            Medical care is mostly in the form of catastrophically expensive surprises

            So why does the health insurance forcibly sold to USians cover routine care?

            Feature creep. Prior to the late 70's/early 80's, what we now think of as health insurance was sold as "catastrophic insurance". It was often named "hospitalization insurance". It's purpose was to help protect you against the small, but non-zero, risk that you might have something go wrong that was very expensive. And the insurers acted as the risk spreading pool. The 10% that incurred the huge bills had their expenses spread across the 100% who paid in but never got hit with the huge bills. So most people paid in more than they ever got back.

            And, back then, all other routine healthcare was pay-as-you-go. And a Dr.'s visit didn't cost $175. More like $20 (which would be $73.82 in 2016 dollars according to http://data.bls.gov/cgi-bin/cpicalc.pl [bls.gov]).

            Then, somewhere along the way, someone (insurers, govt. bureaucrats, who knows) started noticing that folks didn't go to their Dr's routinely for the periodic checkups that might catch a problem while it was a $1,000 fix long before it became a $1,000,000 fix. And so began a gradual push for "insurance" to cover more and more of the periodic routine checks. The reasoning was that if individuals could be better encouraged to go for the routine checks, and the problems caught before they became expensive issues, that the insurance world could save itself money (read as insurers could increase their profit). The initial logic was sound, catching issues early and fixing them before they become expensive items later is a good way to increase profit in a system based around risk.

            Unfortunately, none of the companies going down this route of increasing their profit by lowering their risk by encouraging routine checks foresaw the unintended consequence of fully insulating the medical system user from the costs of their care. By paying for more and more of the routine stuff, the folks using it lost track of the cost, and generally began to not care (i.e., price competition was reduced) about the costs (because insurance was paying). Plus, this price hiding factor also resulted in far too many idiots believing that insurance is a way to "pay for all my healthcare" at the rate of ten cents on the dollar.

            The reason so many idiots think insurance is a magic way to pay ten cents on the dollar for their health care is because that's all they see happening. They visit their doctor, they pay $20 as a co-pay, they think it only cost $20. At least with the old system, they directly saw the costs and were directly incentivized to try to keep those costs down. With the new "pay for everything" method, they saw none of the real costs, and began to not care because "someone else's money" was paying for the costs. Which brings us full circle to now and the obomacare idiots who think obomacare is a way to 'reduce costs' of healthcare. Insurance never reduces costs it always increases costs (because the insurer has to add a profit premium on top). What insurance does, and what it has always done, is reduce risk to everyone by spreading the risk of an unlikely event happening among the few across a large enough pool of members that the net risk is less for everyone. Converting health insurance from a "protect against huge bill" hedge into a "pay for everything you ever have done" is what is quickly killing the system all the way around.

      • (Score: 4, Informative) by AthanasiusKircher on Sunday August 21 2016, @05:25AM

        by AthanasiusKircher (5291) on Sunday August 21 2016, @05:25AM (#390909) Journal

        At any one time the grocery industry is represented by 2 groups of people:

        While creative, your grocery analogy is fundamentally flawed in too many ways to mention. Perhaps most importantly, health insurance companies serve two fundamentally different markets: (1) people who need basic everyday care that they could probably pay for reasonably just by budgeting, and (2) people who need coverage for catastrophic events that are difficult or even impossible to save for. The latter is more like term life insurance or fire insurance or whatever, where the risk is spread out across large pools of people, most of whom won't actually ever use the maximum benefit. There is no analogue to (2) in a grocery business. Moreover, those who need (2) often are in dire emergency straits, without the ability to "comparison shop" as they might in looking at different stores.

        Anyhow, function (1) is not like any other sort of "insurance" in the normal sense. It's more like an "installment plan" or something, or the "constant payment plan" offered by a gas heat company that lets you pay one standard monthly fee every month to even things out so you won't have to deal with the $400 heating bill suddenly in January. That's really not insurance, nor is it really like anything resembling the market for grocery stores. But that's where people deal with "health insurance" on an everyday basis.

        The grocery companies make a "business" and try to make a profit by charging as much as they can to b). However if they get too crazy b) will just go to another a) and everybody knows it, which keeps things more or less in check.

        That statement is absolutely unequivocally false for the U.S. insurance market. Why? Because no one knows what they are really paying for health care. Wait -- let me say that again: NO ONE knows what they are really paying for health care.

        My vote would be either for a system that limited "health insurance" to catastrophic incidents only, definitively separating that coverage from any "monthly gas-bill" like way of distributing your payments for annual physicals and flu shots... and requiring the charges for the latter services to be available upon request to practice medicine. OR, go with single payer, and kill that nasty cobra (no pun intended) that serves little purpose in standing in the way between doctor and patient, while simultaneously reducing the cost of healthcare by maybe 25% by getting rid of the insurance industry. (Or, well, I don't think private supplemental insurance should be outlawed, but with a reasonable single-payer system it should decrease

        That's particularly true in insurance plans with "co-pays," where the actual price billed by the doctor's office and the amount paid by the insurance company for service are dealt with internally. A patient might receive a statement detailing all of those "charges" (the reason for quotation marks will become clear in a moment), but since you already paid your co-pay, all of those numbers are pretty much meaningless to you. It's only on those more rare (and frequently unpredictable) occasions where "coverage is denied" for something that you really need and have to pay out of pocket that you realize the actual cost of anything. And since those things are difficult to sort out except for those who can read the multi-hundred-page annual insurance manual they get with their policy, it's hard to know when coverage will fail. Which means it's difficult to "comparison shop" between plans.

        "But wait," you say, "what about those high-deductible plans many people have nowadays? In those cases, you end up shelling the first $5000-13000 per year out of pocket, so surely you see your 'real cost'??"

        Except you don't. What you see is this weird set of manipulated numbers which involve the numbers the doctor's office claims to "charge" and then the amount your insurance company says they will pay (which is generally a negotiated fee with a discount, which varies depending on your insurance company, what group of policy holders you're in which affects negotiated costs, etc.). So, again, you see a bunch of money transferring, with one party saying "You owe X" and another saying "We paid Y," but you have no clue how that might relate to the amount you might owe or what your insurance company would pay if you had a different insurance company or no insurance at all.

        And it's next-to-impossible to get estimates for healthcare services ahead of time. You might be able to get the standard charge for a doctor's visit with no tests or special conditions in advance. But hospital A might charge four times as much for an out-patient procedure as hospital B, but it's almost impossible to get that information ahead of time, since it doesn't only depend on the actual claimed "charges" the hospital bills, but then what your specific insurance company has negotiated with that particular hospital or hospital network.

        Bottom line: you pay a monthly premium, sure. But it's basically impossible to "comparison shop" among insurance companies or healthcare providers, which make your free-market comparison with grocers very problematic. For a patient to be able to make an informed choice to leave an insurance or choose a different provider, they need to be able to get information about actual pricing and costs, which you can't do.

        And even if you think you know the way your plan is supposed to work, there's no guarantee it will. When I switched to a high-deductible plan a few years back, I thought it was a good decision for a number of reasons. But it also meant I kept a closer eye on my bills that I was paying out of pocket. Except discounts my insurance company said should apply wouldn't necessarily apply. The "free annual physical" with all sorts of specific tests was denied to be covered -- until I went back and forth between my doctor's office and the insurance company with literally a dozen phone calls spread out over 6 months and FOUR TIMES having the claim refiled until I could actually get it resolved. (Actually, in the end, the doctor's office still made an error in coding, so one of my procedures still wasn't covered when it should have been, but they accidently put a double credit on my account for another reimbursed test that landed me about $3 ahead of what I should have, so I just gave up and quit the "medical billing shuffle" while I was ahead. And all of this was over charges for a standard physical with no unusual tests or anything.)

        Imagine if you had grocery "insurance". All of b) would want steak for dinner every night.

        Imagine if you had "single payer groceries". All of b) would want steak for dinner every night.

        You know what? I don't want "steak dinner." I just want a transparent billing procedure and reasonably accessible and accurate cost estimates for non-emergency procedures. If we had those things, we might have something resembling a free market where a consumer can make a rational choice between insurers. We do not. And people on all sides -- doctors/hospitals, insurance companies, and patients -- make unreasonable demands in these situations, because nothing is transparent.

        Insurance and freebies is the problem, not the profit motive.

        Well, this mess we call "insurance" is the problem -- I agree -- due to an extra layer of unnecessary bureaucratic profiteering mucking up stuff in the middle. I have no problem with a doctor earning some money for services. The "profit motive" of the middleman is the problem here, and there's really no good reason for it to be there.

    • (Score: 0) by Anonymous Coward on Sunday August 21 2016, @01:07AM

      by Anonymous Coward on Sunday August 21 2016, @01:07AM (#390809)

      payers and withdrawers?

      YOU forgot two other important participants

      1) the insurance companies taking their cut
      2) the providers, especially pharma taking their profits.

      and of course govt, taking more control to do it 'their way', which is what got us to the state we are in.
      that is, where there is little feedback between cost and actual benefit.

      A private system with the feedback works, but is pretty harsh for folks without cash.
      A public system with the govt being the provider via civil service seems to work in other parts of the world.
      (Some say these systems are only working because good ole US capitalist is providing the drug research.)

      The US seems to be trying to demonstrate that a mix of public and private is possible. (I don't think connecting these profits to the public hog trougth is sustainable.)
      Remember Churchill: the Americans can trusted to do the right thing after they have tried everything else.
      Just hope I survive until they switch to the right thing.

      • (Score: 0) by Anonymous Coward on Monday August 22 2016, @02:50AM

        by Anonymous Coward on Monday August 22 2016, @02:50AM (#391426)

        The US isn't the only one with a mix.

        Germany and the UK both do, to my certain knowledge. There are probably others. I think South Africa may be one. Canada kind of does (its private sector has been largely bullied out of existence, but may be recovering after some court victories).

        The government being the sole provider tends to work OK for things like falling off a roof, having a car crash, and regular vaccinations. By modern standards, basic stuff. It's dealing with more complex, chornic conditions, or where the formulary has to be quite flexible, that they come unglued.

        There's a lot of research in this, you could probably learn a lot in a few hours with Google.

    • (Score: 0) by Anonymous Coward on Sunday August 21 2016, @05:15PM

      by Anonymous Coward on Sunday August 21 2016, @05:15PM (#391095)

      Good news! NPR didn't get it quite right!

      Turns out, there is incentive to lower costs, and the insurance market is supposed to be that, as long as there is competition among insurers, and insurers have the muscle to push providers in price terms.

      What has not been solved yet is the problem that while we are getting more nurses, nurse practitioners and so on, our supply of actual MDs has not been growing reliably, and is actually falling.

      Lots of people want to pooh-pooh this, pointing out that lots of people want to become doctors, and so on (hand-waving here the AMA's gatekeeper function keeping the supply down) but we don't have to wonder in the abstract how it will turn out; we already have a case study in a closely-related field: large animal veterinarians.

      It's a poorly paid job, compared to suburban vets, it's a hard and draining job, and every bit as tough to study for. Result: we're running out of large animal vets. But what does it matter? Who cares about them? Only our entire agricultural system, pretty much.

      Oh, dear. Maybe this might be a problem.

  • (Score: 0) by Anonymous Coward on Saturday August 20 2016, @09:19PM

    by Anonymous Coward on Saturday August 20 2016, @09:19PM (#390718)

    It was a crony socialist conspiracy pushed by the big pharma, the liberal establishment and MSM. And Wall Street and George Soros were in on it too.

  • (Score: 2) by jmorris on Sunday August 21 2016, @03:36AM

    by jmorris (4844) on Sunday August 21 2016, @03:36AM (#390865)

    Obamacare was designed to fail,

    Exactly. look up the video of Jakob Hacker (described as the Architect of Obamacare) explaining how Obamacare isn't a Trojan Horse for Single Payer because 'it is right there.' Meaning it was so obvious it couldn't be accused of being hidden. It was so obviously designed to fail that he wasn't going to dispute it. The idea is to hook so many people on it before all of the insurers pull out that the cry for the government to 'do something' will carry them to exactly where they wanted to go in the first place but the political will was lacking. Look at this article summary where the call to just make Medicare universal is already being bleated by morons who can't do math. Medicare is already broke, adding millions more unhealthy people to it will only bring on the kaboom faster and harder.