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.