The Aetna Change and How the world of Health Care providers works


-There is no such thing as an “Aetna Plan”. There are multiple (low end, medium and higher end, if you will) Aetna Plans from which the MTA selected.

-The main object of the MTA’s exercise was to save money by re-shopping the coverage as they work their way to lower cost, lower end coverage. Unquestionalbly, the MTA went with what it thought it could get away with, bearing in mind that no one was watching the store. 

-Eack “network” is not really some closed”network” but a list of enrolled service providers that accept the reimbursement rate negotiated and virtually all service providers belong to multiple “networks” – as many as a dozen in some cases – to pay their bills and maintain a profit margin.

-A competing network, by definition, offers and often guarantees a cheaper price, and savings – at least in the first year – compared to the “network” they are competing to replace. Switching networks is like switching car or insurance or cable service providers. They make their money from under pricing the competition and raiding them. Then once they have you, they turn to squeezing you to make money. Sounds familiar? Its not unlike dealing with drug pushers or thugs running neighborhood protection racket. No ethics there, none!

-Our protection is the value of our numbers, which all the drug pushers and protection racketeers want. Did we exercise that leverage or hand that leverage over to the MTA as its leverage to use against us … to turn around and reduce our benefit instead? All indication is that the latter occurred here.

-To cover their asses, the competing network and the MTA may or will claim that their network provides at least comparable service providers by volume, speciality, type of service, geographical distribution etc.

-Its not a ‘pig in a poke’ business. Its not like sticking your hand in a bag where you don’t get to see what’s in it. They come with “list(s)” to get your attention and your business. But it requires actually looking into the bag!

-Problem is, no one looked for us?!?

-Each network likely has list(s) to show that they are comparable, which is often never carefully checked in detail and is at best just scanned by the MTA for overall data points.

-Problem is, that these “lists” are always in flux, changing from day to day, as service providers go in and out, all the players know this even if they pretend otherwise. A 10,000 service provider list easily becomes 9K or 8K or 7K ( a 10% or 20% or 30% reduction) within a year or two without it becoming known and never reported. A provider change here and there doesn’t show much. Changes in the aggregate numbers show more. On our end, we learn about this one member at a time, to one rep at a time which mostly just become shop talk. We never have the aggregate numbers by geographical distribution necessary to truly and properly track the changes in service and therefore in our benefit.

-What drives away or attracts service providers is the fluctuation in the reimbursement rates by service and procedure provided. That’s an important lever from which the network extracts profits and calibrates its profit margins.

– A “network” agrees to cover X numbered of “covered employees” and X number of “covered lives” (families). Once they get the contract, they have a savings incentive (which they can share with the client (the MTA)) to reduce the headcount, which is why in the last change, some 7,500 souls saw their benefits ended. The new provider is encouraged to ‘check the cupboards’, scrub and purge the new lists delivered to them, that is, after they negotiate a blended price of $X per covered employee and $X per medical service/procedure. How does the network make money? – They pay the actual service provider $X minus, per service/procedure. The minus is their profit multiplied by the thousands of service/procedures. This drives service providers in and out, like a revolving door, but going downhill.

-Other especially vulnerable groups can include members that require high maintenance, with established and less complicated clearance procedures to access the coverage they need. Active members living ‘off the beaten path’, and then of thousands of retirees spread across the expanse of the country are also particularly vulnerable.

-Under the 2002 contract, unlike almost any other contracts in the labor movement, the MTA is obligated to provide a “defined benefit”. It is prohibited from changing the benefit. Its a gold standard for this business. But that requires constant policing.

– Instead, John Samuelsen’s people whole approach from day one, has been to convince Transit workers to expect bad things to happen to their health benefits. To expect them to deteriorate from year to year, because management has been given the right to do as it pleases with them. Under them, the union itself is ‘riding shotgun’ for the changes the MTA wants to push through.

-Steve Downs, Nicholas Bedel and the rest of John Samuelsen’s basket of deplorable sellouts have already openly declared that the MTA did what it had the right to under the contract. Blinded by their desire to make my administration look bad, once again and cynically, they rationalise and bless the MTA’s highjacking of our families health benefits!!!

-They have openly declared that the contractual obligation for the MTA to provide the benefit “directly” is meaningless and that that obligation can be simply transferred to a third party at the MTA’s sole discretion. They put that in writing and announced it to the world, and for the MTA to run with!

-John Samuelsen and our Union, never checked and never even demanded or held the quarterly meetings required by signed agreement to control and police the process or pass on or challenge any choices being considered or undertaken. I believe that he has failed to even conduct any of the 27 meetings(!!!) he was required to conduct since he took office in Jan 2010 and NONE in the lead up to the latest change just as he did NONE in the lead up to the last change!

-Cynical! Foul! Criminal! Foolish Sellouts they are!

They deserve the most forceful collective and all-sided challenge from the members and retirees of Local 100.

They have joined with the MTA to attack your sacred responsibilities to your families.


– Roger Toussaint

Instagram: ProgressiveAction

Twitter: ProgressiveAct


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