Wednesday, April 17, 2024

It's all corporate now. Why do we stand for it?

"Sick. Help. That’s it!”

“John Q,” played by Denzel Washington, whose son needs a heart transplant which the insurance company has denied coverage for


There are still people in health care – admittedly mostly administrators and pundits and some doctors, highly-paid folks who think of themselves as “leaders” rather than “bosses” – who see the restrictions that the health insurance system places on people accessing health care as a good thing. They say that it keeps the lid on health care costs by limiting the use of “expensive and unnecessary” services by people who want “too much” of it. Luckily, for me, I no longer run into those with such views very often, and I like to think that there are fewer of them now.

These are often the same folks who supported, and continue to support, “managed care”, generally thought of as HMOs and PPOs, and their senior partner, Medicare Advantage plans (which are essentially HMOs or PPOs paid for with Medicare dollars). The techniques developed for restricting care in these plans have now been adopted by the health insurance industry overall. “Prior authorization”, which often means “delayed or denied authorization” has become one of the key strategies for restricting your access to health care services.

Restricting your access to health care is presumably not the specific intention of these practices. It would be mostly incorrect to portray health insurance executives as mean, grasping devils rubbing their hands together, like Mr. Burns, the boss in “The Simpsons”, in pleasure at your pain. They are actually mean, grasping devils rubbing their hands together in pleasure at the amount of money that they are making; your pain is incidental. I don’t know how many look like Mr. Burns.

HMOs, or what we now call HMOs, were not always money-grubbing deniers of care. Most of the early ones were consumer cooperatives (with the notable exception of Kaiser-Permanente, developed by Henry Kaiser for employees of his steel company, so he and not the insurance companies would make more money) like Group Health in Seattle, HIP in New York, and Ross-Loos in LA, designed to cut out the insurance companies so that members could get the same care for less money, or more care for the same money.  Without the profit motive in play, truly unnecessary care (sometimes that had been ordered by physicians or hospitals who stood to make money on it) could be avoided, and more necessary care provided. They often contracted with physician practice groups that were owned by the physicians themselves, rather than a corporation that violated the laws against corporate practice of medicine. Kind of vaguely socialist. Kind of good for people. Kind of quaint.

If you’re old enough, you may remember this kind of thing. In the 1980s the Reagan administration sought to expand them (naming them HMOs) as a method of cutting the cost of health care. Or, at least, cutting the costs that were expended in delivering actual health care. The plan involved encouraging insurance companies to buy up and establish their own HMOs, so it wasn’t too long before the reality of a consumer cooperative HMO was, in most places, history. Owned mostly by insurance companies, and increasingly with vertical integration, those dollars formerly “wasted” on providing “unnecessary” health care could now be turned into executive compensation and corporate profit. Some people may think this is a bad trade-off, that making money for corporations instead of providing health care for people is truly waste, but those holding such anachronistic and na├»ve ideas are wrong. At least in the opinion of those controlling the corporations! And their policy apologists.

This innovation was such a success (at making money) that it was expanded to a much wider base of health insurance. The old kind of insurance (often managed by the non-profit Blue Cross/Blue Shield, before they became the for-profit Anthem), that covered people for their health care needs, did not try to beat them down with denials, paid a reasonable amount to providers, and took a reasonable fee for their work, gradually became a thing of the past. These were sneered at as “Cadillac plans” (only when the beneficiaries were union members, of course not when they were executives!)  losing hold with each successive series of union contract negotiations. The executives kept their solid gold Cadillacs while union members and other employees were pushed lower and lower down until their coverage became a shadow of what it formerly was, and they often found themselves denied the care they needed and used to get.

There is a little historical irony here, in that the labor movement sowed the seeds of its own destruction by making health insurance a contract benefit. After World War II, unions in other countries fought to make health care available to all people; in Britain the party that was elected to govern actually had “Labour” in its name and introduced the National Health Service. In the US, the government instituted wage and price controls, so, unable to bargain for higher wages, unions bargained for health insurance as a way to recruit members. It was good for the members, but not so good for the nonunionized workforce. And the bosses liked it too; employer contributions to health insurance are not taxed, whereas wages are. Anyone who thinks that that such things as employer-sponsored health insurance is a “generous benefit” that is not paid for by the employee through lower wages is wrong. So, while the poor and non-unionized ended up on their own, the US labor movement got its members health insurance, often excellent health insurance. For about 30 years.

Now it’s all owned by corporations, the whole shebang. Insurance, providers groups, pharmacies, nursing homes. Many of these corporations are insurance companies, like the biggest, UnitedHealth, which also owns doctor group Optum and pharmaceutical benefit (PBM) manager OptumRx. And I am sure that, while many practices went under because they weren’t paid as a result of a major cyberattack on United subsidiary Change Healthcare, United itself is doing fine, making $8.5B in the first quarter (after all, by not paying those practices, they got to keep their money in the bank paying interest)! Other corporations are owned by private equity funds, which don’t even pretend to have any interest whatever other than maximizing their profit. Indeed, these are arguably even worse since they are sometimes happy to destroy the companies (and thus the services they provide) if that makes them the most.

The idea that a significant part of the cost of health care is overuse of services by patients would be pretty funny if it were not so serious, and for the fact that any such overuse is dwarfed by the number of people not getting adequate care, paying too much (in premiums and deductibles and co-payments and lost wages) for care, or being unable to access care altogether. That is the big problem, and as always it is the lowest income (and disproportionately minority) people who are hurt worst.

And even if you do believe that overuse is a problem, there is no conceivable way that any half-sentient, half-decent human being could possibly believe that money going to corporate and private equity profits is not waste and is a better use than providing health care to people. It is amazing that there any who do, but they include a lot of folks being paid by them – including members of Congress.

So: tell your Congressperson that YOU don’t think so, and that money appropriated for health care for people should be use for that, not raked off by insurance companies and other corporations, and it is their job to make that happen!

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