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.