Being blown off by health care can cost you your life...

Dealing with corporations is hard. Robots answer your calls, but not your questions. They are programmed to give you the information the company wants you to have, not the answers you need. It is very difficult to ever find a “monitored” email address to write to. It is like they don’t want to hear from you (except in the ubiquitous and totally structured “tell us how we’re doing” requests). Charges (as I experienced recently) are posted to your credit card immediately. Refunds, even when they agree to one, can take 45 days (by policy).

People, on the other hand, are almost always good and helpful. If you have the time and patience and willingness to scream “representative” at the phone often enough to actually get one, they mostly are polite, empathic, and usually resolve your problem (unless such resolution is prohibited by company policy). At least they answer your questions. It is amazing but not surprising that companies make it so hard to get to them. After all, they may help you out. Which is not what the company wants; they want your money and you be gone! Robots are also cheaper, thus increasing profit (and unemployment).

And so it is with healthcare. In which case it can be a disaster. I don’t mean that the waste of your time and money with other corporations is ok, or even just bad, or that it cannot financially be a disaster. But in health care we are talking about the health and even lives of you and your family. If you can’t get hold of your health care providers, you can’t get seen and cared for, or get the information that you need to do what you need to do, or to be seen elsewhere. This is, again, not the fault of or the result of the actions of the actual people who care for you, who if you can get in to see them or speak to them on the phone are usually very helpful. It is the fault of the system that is structured to prevent you from getting to them, because less use by you results in more profit for them.

That, of course, is at the provider level. At the insurer level, we enter a whole new region of Bizarro World. You get insurance. You find a provider. You see your provider. They recommend a treatment plan. You agree. Now the insurance company, which has a policy requiring “prior authorization” for virtually everything, denies payment. There may not be a good, or even any, medical reason for denying payment, and, if you appeal, they may pay because, after all, there is good medical reason. But denial as a first line response is great -- for them. Most people don’t appeal. They often don’t know that they can, or how to. So, for the insurer, problem solved. Of course, their problem was that they were going to have to pay money, and now they don’t. Your problem? Not solved. And your problem was your health, treatment for your disease. Whoops.

Prior authorization is an effective tool used by insurers to not pay for your care. It is more ubiquitous in “managed care” plans (HMOs, PPOs) than in open insurance plans. Of course, the latter are getting much rarer. It is cheaper for your employer to enroll you in a managed care plan. (Noticing a theme here?) Medicaid the (almost always dreadfully inadequate) public state/federal partnership for covering the poor is mostly (41 states including DC) turned over to managed care. One of the last bastions for fee-for-service, Medicare (the federal insurance plan for the aged, blind, and disabled) is quickly moving in that direction, with over 50% of Medicare patients not enrolled in actual Medicare but rather in “Medicare Advantage” (sic) programs, essentially private HMO-type plans paid for with Medicare funds. Now Medicare patients too can experience the advantages of managed care (like eyeglasses and gym memberships) as well as the disadvantages (like limited provider networks and denials of payment when you actually get sick).

A lot of the burden on privately-insured patients is demonstrated in research by Sukreth A. Shashikumer et al. in Financial Burden of Health Care in the Privately Insured US Population,
JAMA Internal Medicine, May 28, 2024, and summarized in the Health Justice Monitor.  

Among low-income families, mean total health care spending was $3163 in 2007 and $3247 in 2019. Low-income families’ medical burden was 23.5% in 2007 and 26.4% in 2019.  Among higher-income families, mean total health care spending increased from $4071 in 2007 to $5239 in 2019. Higher-income families’ medical burden was 5.4% in 2007 and 6.5% in 2019.

It’s bad for everyone but is, as always, worse for lower income people. This is also described in detail in a recent article by the Associated Press’ Tom Murphy, “Being a patient is getting harder in a strained and complex US health care system” (June 2, 2024), which describes the direct negative impact of insurance company denials on people’s health. The article discusses how some coverage for patient navigators helps, but the core problem is that is in the interest of the insurer to not spend money. Some MA plans like to say that they are enhancing health equity by covering a lot of low-income and minority people. Of course, this is only because the up-front costs are less. Those people pay when they get sick not only with dollars (co-pays, deductibles) but with their health (limited networks, denial of care).

And the majority of Medicaid recipients are children, and they are not immune from being denied care by their insurance companies, as revealed in a report from the General Accounting Office (GAO) and described by Wendell Potter in his “Health Care Un-covered” substack. It reports that insurers use both prior authorization and denial of payment for services, called EPSDT (Early Prevention, Screening, Diagnosis and Treatment) that the law REQUIRES be provided!

Contrasting traditional (real) Medicare with Medicare Advantage is useful here. You pay into Medicare your whole working life. When you are old enough and receive it, traditional Medicare pays for the services you receive (with some important limits, mainly only 80% of hospitalizations, requiring a Medigap plan). Medicare Advantage however, receives the money for your care from Medicare up front. Their incentive, then, is to keep it, by spending as little as possible on your care. That’s it in a nutshell. It is described in more depth in the report from Physicians for a National Health Program (PNHP), “Taking Advantage: How corporate health insurers harm America’s seniors.”

It is awful how badly corporations treat people. The laws and regulations need to be changed, to require them to provide the goods and services they have been paid for, and to make access for concerns or complaints, including access to actual people, easy. But completely different rules need to be in place for healthcare. If I can’t get through to most companies until Monday, I can live with that. If my credit card company keeps me going through the hoops on the phone for a half hour or more before I can talk to a person, I am only wasting time. But if this happens when I am trying to access health care, I can get very sick or die! Waiting 6 hours to be seen in the ER is not the answer. Neither are prior authorization, denials, and delays, for sick children, vulnerable seniors, poor people, or any of us.

What can we do? Write and call our congresspeople and demand that they eliminate profit-making insurers from healthcare. Perhaps some are not stupid (believing what lobbyists tell them, such as that Medicare Advantage increases equity) or corrupt (gleefully accepting those lobbyists contributions) and actually care about the health of their constituents.

Tell them to sign on to the Improved and Expanded Medicare for All bills in the House (Pramila Jayapal and Debbie Dingell, primary sponsors) and Senate (Bernie Sanders), and to sign the Patients Over Profits pledge being promoted by National Nurses United and other organizations.

Or you won’t vote for them.

The vicious cycle of corporate profit in healthcare: Less healthcare for you

It is a little difficult to focus on writing about the terrible things happening in US healthcare given all the terrible, existential, threats to the nation and the world. Yet it is not unrelated. The abuses and rapacity of the US healthcare system is a microcosm (although, in this country, a BIG microcosm) of the tremendously damaging outcomes that arise from a system that is based upon the insatiable greed of a few and their willingness to use their wealth to fuel lies, wars, and climate change, and to attack democracy, to further line their pockets.

So it is in healthcare. An industry that is ostensibly devoted to maintaining the health of, and treating and sometimes curing the diseases of, the American people is consistently revealed as nothing more than an industry, devoted to making as much money as possible. Pretty much period. It does not, as an industry, care about your health, or that of your family. This is not to say that the people who provide health care do not; almost uniformly the doctors, nurses, pharmacists, therapists, and others are working hard to do the best that they can for your health, motivated by the commitment that took them into their field in the first place. But fewer and fewer of them are in control of their own practices; most are employed, and even those who work for themselves must almost always work with institutions that are corporate and dedicated to that holiest of holies, the bottom line. (To be sure, there are a few independent practitioners who can deliver their services on their own without the involvement of hospitals, drug companies, insurance companies, etc., but there are few and the care that they can provide is almost always narrow and limited. If that is all you need, you are in luck. For now.)

Revelations continue apace about the extent to which this is true, to which almost all efforts in health care are geared toward garnering profit. There is very rarely news that is good for the health of the public, although it often is for the stocks of the corporations involved, the profits of the private equity companies that often own them, or the salaries of the C-suite executives of those that are “non-profit”. We almost never see a change that is likely to increase the quality, quantity or distribution of healthcare even if it might cost the company more. Quite the contrary, changes almost always involve restricting healthcare in terms of what is available and how much it costs the recipient in various ways (premiums, deductibles, co-pays). We also see a consolidation of ownership, frequently involving vertical integration (where, say, the insurance company owns the providers of care -- as in the case of UnitedHealth and Optum -- and essentially pays itself), an exploitation of public funds and redirecting tax dollars intended for healthcare provision into profit (see Medicare Advantage), and a huge amount of money going into profit and incredibly bloated salaries.

I almost said “ever increasing” profit, but this is not true. The amount of profit is not always increasing, although it remains obscenely large. Sometimes this is interpreted by “the markets” (a benign-sounding euphemism for the rapacious predators that they are) as a problem; even when profits are increasing, but not at the rate investors want them to, insurers and healthcare corporations are pressured to further cut back services and increase premiums and charges, always to the detriment of the health of the American people (as per this Wall St. Journal article).

A good summary of the many ways in which the health of Americans is sacrificed on the altar of profit is a JAMA Viewpoint titled “Salve Lucrum: The Existential Threat of Greed in US Health Care” by Donald Berwick, former administrator of the Center for Medicare and Medicaid Services (CMS) and co-founder of the Institute for Healthcare Improvement (IHI). The Latin phrase means “Hail Profit” which Berwick observes was found under a mountain of ash on the mosaic floor of a grand house in Pompeii, and that it would, sadly, be an appropriate motto for many of our healthcare institutions. Berwick goes through the various components of our system, showing how – and how much – they maximize profit by sacrificing health, especially making every effort to tap into “deep pockets” (particularly government-funded programs like Medicare) and avoid the poor, sick, and poorly-insured, even though those often are the people most in need of healthcare.

Medicare Advantage (MA) is the program that takes money from the Medicare trust fund and transfers it to private insurance companies to enroll Medicare beneficiaries in essentially HMOs. MA programs receive more money from CMS than it spends on traditional Medicare beneficiaries and uses some of it to provide services that are attractive and not paid for by traditional Medicare such as glasses, hearing aids, and gym memberships. As with non-Medicare HMOs, some people benefit from the integrated services, absence of co-pays and ease of use, as long as they are happy with the options of providers (always limited). And so long as the services they need are approved by the insurer – remember that MA is not actually Medicare but a set of programs run by private insurance companies that can, and do, deny and delay services, often through a process called “prior authorization”. But whether clients are receiving the healthcare that they need or being screwed out of it, Berwick notes that

By gaming Medicare risk codes and the ways in which comparative “benchmarks” are set for expected costs, MA plans have become by far the most profitable branches of large insurance companies. According to some health services research, MA will cost Medicare over $600 billion more in the next 8 years than would have been the case if the same enrollees had remained in traditional Medicare.

Insurance, including health insurance, companies in the US have always been for-profit with few exceptions (the traditional Blue Cross/Blue Shield, for example, although these have now almost all been converted to for-profit). But the profits that they are making now are extreme. Pharmaceutical companies have always been for-profit and have long been the healthcare industry poster child for overpricing and holding people’s health hostage to their making money. Direct service providers (e.g., hospitals and doctors) have increasingly been acquired by for-profit operations, especially insurance and private equity companies and those that remain officially “non-profit” compete by playing by the same rules as those that are not.

Some of the problems with Medicare Advantage programs have come to the attention of Congress, which is concerned about their exploitation of public funds, but what will come in terms of reform is questionable. Many congresspersons actually believe in the transfer of public funds to private companies. These insurance companies have very deep pockets (from the government) with which to lobby those same officials (kind of like the defense industry). They also cite the increasing percent of Medicare beneficiaries (now over 50%) who have “chosen” MA plans (or, often, been pushed into them by employers, including local governments) as evidence that they are valued. Of course, the healthier you are, the more marginal benefit you get from the MA perks; the sicker you are, the more in need, the more those denials and delays harm your health. And, always, at any given time there are fewer very sick people than those who are relatively healthy, even though serious illness is often in their future.

If Congress addresses MA at all, it is likely to be tweaks around the edges. What, instead, needs to happen is the closure of MA, increasing financing for traditional Medicare to fund ALL health needs for its beneficiaries, regulation of the pharmaceutical industry, and a change to a healthcare financing system, such as Medicare for All, that make the health of the people and not the profit of the corporations, the goal of the system.