"Health Care Un-covered": Covering the abuses and heartlessness of the health insurance industry is a big job!

The former health insurance executive turned whistleblower Wendell Potter provides outstanding service on his substack “Health Care un-Covered” by revealing abuses within the insurance and greater healthcare industry (well, abuses to him and to me; SOP to the companies!). Recently, Trudy Lieberman, a past president of the Association of Health Care Journalists posted there “Deny, Defend, Depose”, words made famous by being inscribed on the bullets used to kill UnitedHealthcare CEO Brian Thompson. She discusses early meetings in the 1990s when health insurance coverage was migrating from covering “major medical” to “managed care”, where the company paid for – and sometimes controlled directly – all the care you received. Managed care, as a concept if not a term, existed way back in the 1950s, when “consumer cooperatives” like HIP in New York, Ross-Loos in Los Angeles, Group Health in Seattle were established to reduce the cost of healthcare by eliminating the middleman – the insurance company – and could either provide more care to members for the same money, or similar care for less money. When, first under Nixon and then Reagan, this concept was expanded, many people (like me) were fine with it because of our positive experience with the consumer cooperative version.

Under the new version, however, a different type of managed care emerged which, rather than excluding the insurance companies, was owned by the insurance companies, often even employing the physicians and other clinicians who provided care. Thus, a third option emerged: rather than either saving consumers money or providing them with more care, these companies could provide less care and pocket the savings! She writes

New perils came with that new age of health coverage. In the quest to save money while ostensibly improving quality, there was always a chance that the managed care entities and the doctors they employed or contracted with – by then called managed care providers – could clamp down too hard and refuse to pay for treatments, leaving some people to suffer medically.

And this is what happened and continues to happen. UnitedHealth is not the only company to profit handsomely (an understatement) from this setup, but it is the largest. The three words in the title (and on the bullets) summarize the strategies used – deny claims for healthcare, defend any challenges in court (these costs being less than the profits) and depose patients, making their lives miserable.

When these changes were being instituted, there were many in the policy arena who advocated for them as a means of cost control, citing the “overuse” of healthcare by Americans as the main reason for the high cost of our health system compared to that of other countries, which needed reining in by supposedly responsible bureaucrats. They were wrong then, and they are wronger now, when it is clear that the cost to the system of people “overusing” healthcare (whatever that means) is miniscule compared to the amount of money being taken out of the rest of the economy in terms of profits for health insurance companies, and to some degree to providers (e.g., hospital systems). The cost of US “healthcare” compared to other countries has risen, although the amount of actual healthcare we get has not, has gone down, demonstrated by the lower health status and increasing mortality rate of Americans.

In a post written by Potter he describes one of the main ways that UnitedHealthcare (and others) siphons money from the public sector, Medicare, into its pockets by not only the “3Ds”.

UnitedHealth has taken a unique approach to Medicare Advantage: directly employing thousands of doctors and arming them with software that generates diagnosis checklists before they even see patients.

This is a tactic to enhance the strategy of upcoding, ensuring that they get more money by documenting every possible problem a person might have, even if not relevant to the reason that they are being seen. In Medicare Advantage (managed care for Medicare patients, in which UnitedHealth is the largest player) this is even more insidious; in MA plans Medicare pays the insurers not for the care provided but by capitation, paying more for sicker patients. Thus, documenting every potential sickness makes them more money. Of course, the theory is that sicker people cost more, and so the insurers need more money for them. That would be good, but UnitedHealth and other insurers have figured out how to get more money to go in their coffers, however, not to the care of patients, by often using extraneous diagnoses that do not increase the amount of services rendered or the care people receive.

In a related documentation of abuse by players (insurers, providers, drug companies) in the “health sector”, Becker’s Hospital Review reports on the Shkreli Awards given out by the Lown Institute. Named after Martin Shkreli, the Turing Pharmaceuticals CEO who in 2015 “acquired a 62-year-old drug called Daraprim and, overnight, increased the price from about $13.50 per pill to $750” (discussed by me in Drug prices and corporate greed: there may be limits to our gullibility, Sept 27, 2015).  I suggested that there were limits because “in 2017, he was convicted in federal court on two counts of securities fraud and one count of conspiring to commit securities fraud, resulting in a 2018 sentence of seven years in prison. In 2022, a federal judge ordered Mr. Shkreli to repay $64 million for hiking the price of Daraprim and imposed a permanent ban on his executive roles in public companies and a lifetime ban from the pharmaceutical industry. He was released early from prison that same year.”

But that was then. Based on the activities described for the recipients of this year’s Shkreli Awards, including UnitedHealthcare, which came in #2, Shkreli himself was a piker. BTW, the #1 spot went to Former Steward Health Care CEO Ralph de la Torre, MD.* So I guess the idea that there are limits to our gullibility, or to the greed of these people and corporations, and the willingness of “regulators” to tolerate or even enable it, was optimistic.

However, a positive is that the Consumer Financial Protection Bureau (CFPB) has finalized a rule that would bar medical debt from appearing on Americans' credit reports. Potter observes that

“This progress did not happen in a vacuum. Addressing the medical debt crisis has been a growing priority for policymakers, patients and organizations like Be A Hero, Undue Medical Debt and the Lower Out-of-Pockets (LOOP NOW) Coalition, which I lead.

My team and I, through LOOP NOW, had the honor of helping facilitate a White House event in which Vice President Harris and CFPB Director Rohit Chopra laid out the administration’s plans to address the crisis. That event wasn’t just about policies — it was about amplifying the stories of people like Lindsay, a single mother saddled with $50,000 in medical debt after her insurer denied coverage for her child’s life-saving brain surgery.”

Potter notes that “This single action could wipe $49 billion in debt from the credit reports of 15 million people, offering relief to individuals and families that have had their financial futures derailed by the unforgiving realities of our health care system. If you’ve ever struggled with medical debt—or know someone who has—this is a moment worth celebrating.”

And indeed it is. Until the new Trump administration reverses it, as they probably will, along with abolishing the CFPB altogether.

 

*”Lown Institute awarded Dr. de la Torre the top spot for bad behavior in 2024, which was the demise of Dallas-based Steward Health Care. The for-profit chain was on a buying spree in recent years. Four days into 2024, hospital landlord Medical Properties Trust reported Steward was $50 million behind on its rent. When The Boston Globe published local reporting on the state of affairs at Steward's Massachusetts hospitals, lawmakers and officials started to pay closer attention and the house of cards began falling apart. By May, Steward reported $9 billion in debt and put all of its hospitals up for sale. Dr. de la Torre resigned in September, days after the full Senate voted unanimously to hold him in contempt after he did not comply with a Senate subpoena.”

Healthcare and Public Health: Issues from 2024 will continue into 2025

As we end the year and begin a new one, what can we say was the most important health-related story of 2024, and what will be the biggest in 2025? Certainly, late in 2024 a huge story was the murder of Brian Thompson on the streets of New York. This was not in any way a random killing, but an assassination of someone the killer believed was responsible for hundreds or thousands of deaths in his role as CEO of UnitedHealthCare, the nation’s largest health insurer. As I discussed in my December 8, 2024 post ‘Murder of a Health Insurance CEO: People HATE the companies and the people who run them’, Thompson was guilty of presiding over a company whose role was to make money by collecting premiums and denying care. He also was guilty of having made this problem worse by bring in artificial intelligence algorithms, which had been shown to be wrong up to 90% of the time, to deny health care to his supposed customers – I say “supposed” because the only customers health insurance companies really have is their stockholders; the people they insure could be called “victims”. 

 Although much of the mainstream media tried hard to focus attention elsewhere – on the accused killer and his personality, on self-serving nonsensical essays like the one by Thompson’s boss, UnitedHealth Group’s CEO Andrew Witty run as a NY Times Op-Ed, etc. – the real story is the outpouring of fury at the health insurance industry from the great mass and majority of the American people. While most did not applaud the murder itself, virtually no one outside themselves and their paid punditry had anything good to say about US health insurance. Probably the overall public sentiment reflected that of Chris Rock: “He actually killed a family, a man with kids. I have condolences for the healthcare CEO. This is a real person, but sometimes drug dealers get shot.”

Another huge story, which will become even bigger in 2025, is the planned nomination by President-elect Donald Trump of profound enemies of public health to the positions responsible for ensuring that health. Foremost among these, of course, is Robert Kennedy, Jr. to be Secretary of Health and Human Services. Kennedy is well-known as a vaccine “skeptic”, which essentially means vaccine opponent, and if he is confirmed as Secretary and is able to implement policies reflecting the positions he has long advocated, we will see the resurgence of many diseases long gone from American life with accompanying deaths, as I discussed on November 15, 2024 in ‘Raw milk, vaccines, and RFK, Jr: Some dates worth remembering’. Remember polio? Measles? I do, but most do not. Check out the numbers on this picture. This is an incredible threat to the public’s health.

But, ultimately, the real story of 2024 – and probably 2025, and sadly beyond – is the fact that the American people remain the only ones in the developed, rich or really even middle-income, world that do not have universal health insurance or care. This is what would prevent the crises, delays, denials, and deaths that the private health insurance industry heaps upon our population and that engenders the wrath of so many. Indeed, that wrath continues to grow because the people who are affected, either personally or through someone they love such as a family member, who realize the inexcusable evil that the actions of these companies inflict, grows over time. While only a small percent of the ostensibly insured will have a terrible event each year, with more years more people and families experience such terrible events. Also, of course, the practices of the health insurance companies become more restrictive and more draconian, leading to both more delays and denials and deaths and more out-of-pocket costs for more people. In other countries, this happens, essentially, very little or not at all. The following chart presents the dates when other countries implemented universal health care, and when they got rid of it because it wasn’t working. Look at it carefully and you might discern a trend:

The US has a higher mortality rate than many of these countries. Jim Kahn, in the Health Justice Monitor, makes an effort to quantify the extent to which health insurance (or lack of it) contributes to this. It is an estimate, but as he notes, whether 170,000 or 220,000, it is too much. And, more, we spend much more than all these other countries on what we call “healthcare” despite so much of it going to corporate profit, that the fact that there is any excess mortality due to lack of health insurance is even more intolerable.

This might come as a shock to many Americans, especially those who have yet to personally experience the delays, denials, and deaths that the for-profit health insurance industry heaps upon its victims, because we are regularly and consistently told by politicians and pundits that a universal health insurance system would be a bad idea, that it wouldn’t work for Americans. That it would be too costly. That it would limit our freedom. We need to recognize that this is not true. Few of us want to have the freedom to choose which insurance company takes our money and then tries its best to limit our access to care (although, if we can afford it, we might choose the one that does it least). What we do want is the freedom to choose the doctors and hospitals that we believe will provide us the best care for our health needs and have our insurance pay for it. Of course, this is not the freedom that they are talking about; what they mean is the freedom of insurance companies (and to be fair, many health care providers) to make as much money as possible, which is what would be limited in a universal government-run health insurance system. And, oh, by the way, provide the funds to pay for it. Imagine that our health care dollars, from our pockets and those of our employers and our government (from the taxes we pay; the large corporations and billionaires who own them don’t) could be spent on providing us with health care rather than lining corporate pockets!

There are actual examples of “single payer” health care in the US. Military retirees and families are covered by government-funded health insurance through the VA or TriCare. In the military itself, for active duty service members, health care is not only single-payer, it is government run. The other big example of single-payer available to Americans is traditional Medicare, for those over 65 or disabled. Medicare. The most popular government program since…Social Security. Under traditional Medicare, health care services are approved for people who need them and have them ordered by a doctor, not micromanaged for each individual with people (or AI!) denying them willy-nilly. In an alternative to Medicare, people can opt for enrollment in an HMO/PPO like system run by the same insurance companies that insured (and often screwed) them before they became eligible for Medicare, and have it paid for by Medicare funds. This program, misnamed “Medicare Advantage”, takes away the guarantees of traditional Medicare and puts you back a the mercy of those for-profit health insurance companies that have treated you so well before!

This is exactly what we don’t need – erosion of Medicare. We need Medicare to be improved, to pay for 100% of all needed medical care, and expanded to cover every American, cradle to grave, paid for by the money now going to insurance company and pharmaceutical and device company and health system profits. The reason to do it is because it would benefit people, remove the major cause of heartache, loss and bankruptcy in the US, and make us more secure and happy people. The reason not to do it is that these huge corporations would no longer be making their exorbitant profits by taking premiums and denying health care, and thus would not be able to make such large contributions to the legislators who should be acting, instead, for the American people.

What do you want? Maybe in 2025 it is time to let your legislators know!

 

A final thought from Bernie Sanders:

 

 

 

 

Dark Times for Public Health and Healthcare: Will the insurance industry fix itself?

It’s an exciting time for both health care and public health! Anything goes, and almost anything is, or will in the near future! On the public health front, we have the nomination by President-elect Trump of Robert Kennedy, Jr. to the post of Secretary of Health and Human Services. Kennedy has long been what is generously called a “vaccine skeptic” and his lawyer, Aaron Siri, has sued the Food and Drug Administration to revoke the approval of the polio vaccine. Although the NY Times article says ‘Like Mr. Kennedy, Mr. Siri insists he does not want to take vaccines away from anyone who wants them. “You want to get the vaccine — it’s America, a free country." This is disingenuous. If the FDA approval is revoked, nobody will be able to get it.

I have written recently about the importance of vaccines, especially polio and measles, in preventing disease and death (Raw milk, vaccines, and RFK, Jr: Some dates worth remembering, Nov 15, 2024). A series of letters to the Times in response to the Siri article make clear the risk. Read them; they address the science, the controlled trials of polio vaccine, the experience of those who were doctors and children during previous polio epidemics, and touchingly, the experience of dancer Tanaquil LeClerq, wife of choreographer George Balanchine (short answer: no vaccine, polio, and paralysis). In regard to other vaccines, we can read in the Times ‘Tiny Coffins: Measles Is Killing Thousands of Children in Congo’ and imagine it happening in the US as a result of Kennedy’s anti-vaccine actions. Kennedy calls his movement “health freedom” and says that he will give infectious diseases a “break” (whatever that means), but in fact, as described by Gregg Gonsalves in The Nation, RFK Jr. Is Giving Infectious Diseases a Promotional Tour.

I posted on Facebook that I have heard people say “kids get too many shots”, and asked “then which preventable disease do you want your child to die of?” One comment I got from a colleague was that the problem was not that kids get too many shots, but that too many kids get shot! The most recent killings, in a Christian school in Madison, WI (15-Year-Old Girl Identified as the Shooter in a Wisconsin School) were at least the 323^rd this year in the US! THIS is an epidemic, the extent of which people in most other countries cannot imagine, and, like many of us, wonder what will be done about it. Sadly, the answer is going to be very little, if anything; we may be closing out the statistics for deaths from school shootings in 2024, but nothing suggests that 2025 will be any better.

On the healthcare front, things are not getting better. The anger at the health insurance industry exposed by the shooting of UnitedHealthcare CEO Brian Thompson was deep, broad and well-justified, as I wrote in Murder of a Health Insurance CEO: People HATE the companies and the people who run them (Dec 8, 2024). Study after study continues to appear providing evidence that more and more people have inadequate, unaffordable, or no health insurance. The Commonwealth Fund recently published a report that shows Hispanic/Latino Adults Lack Adequate, Affordable Health Insurance Coverage,

and that this led to their having real trouble accessing health care. The breadth of this lack goes far beyond Latinos.

Maybe we can come up with a solution! I think I have already indicated several – mainly instituting a single-payer universal national health insurance program. Or, until we do, capping the amount of out-of-pocket costs a person can have to a reasonable number ($1000?). And limiting the profits of health insurers, or the ways in which health care providers (e.g., hospitals mainly, but also nursing homes, doctors, etc.) act to make money, whether technically profit or “non-profit”, at the expense of people’s health.

Others have entered this discussion. In a remarkable Op-Ed essay in the NY Times on Dec 13, UnitedHealth Group’s CEO Andrew Witty (Brian Thompson’s boss, who makes more than $20M a year) wrote The Health Care System Is Flawed. Let’s Fix It. Unfortunately, what is remarkable about this article is that the Times chose to run it at all, since it makes no significant suggestion on how to “fix” it, certainly none that would threaten UnitedHealth’s profits. It mostly displays the Times’ complicity in an effort to focus away from the righteous fury of the American people with the health insurance industry.

USA Today reports on Seven reasons why Americans pay more for health care than any other nation, and it gets most of them right. (Reason 1: Lack of price limits, Reason 2: Hospitals and doctors get paid for services, not outcomes, Reason 3: Specialists get paid much more ‒ and want to keep it that way, Reason 4: Administrative costs inflate health spending, Reason 5: Health care pricing is a mystery, Reason 6: Americans pay far more for prescription drugs than people in other wealthy nations, Reason 7: Private Equity.) There are a few others, but it is a good list. Despite that, however, it doesn’t come up with a meaningful, comprehensive solution to them, or any of them. Indeed, it ends up quoting the Witty piece referenced above, "We know the health system does not work as well as it should, and we understand people’s frustrations with it,” rather than having any kind of answer. Like, say, universal non-profit health insurance, limits on hospital system (and physician) incomes, and banning private equity and other for-profit players from the health system!

Maybe it is asking a lot for insurance companies, largely the perpetrators of this massive scam that is bleeding the entire US economy, to come up with a “solution”. But USA Today, Commonwealth Fund, and others that do such a good job of identifying the problem should be able to take the simple next step to recommending the fix. In what is to me an amazingly open (if entirely disgusting and reprehensible) acknowledgment of their agenda, CNBC reported back in April 2018 that Goldman Sachs, the huge investment bank (Jamie Dimon, CEO) raised the question (discussing biotech research) ‘Is curing patients a sustainable business model?’.

!!??

Actually, it’s a good question. Maybe the answer is “no”. Most ethical physicians I know (and it is the vast majority who are ethical) have always said something like “I look forward to the day when we can put ourselves out of business”. Investment banks and other forms of private equity, and the insurance companies like UnitedHealth and the providers that they control, do not see this as a positive. Maybe it is refreshing to see such a stark portrayal of the problem? Or not.

But I, and I believe most Americans, would rather see diseases and the people who have them cured, and would be happy to see the profits of any of these profiteers, privateers, just plain ganevem, and the salaries of their C-suite execs and Boards, disappear.