Premiums are up, people are dying and insurance companies are making out like the bandits they are

In “Medical debt ruined her credit: 'It's like you're being punished for being sick'”, on NPR October 6, 2022, reporter Aneri Pattani covered the story of Penelope Wingard of Charlotte, NC, and others who had their credit ratings ruined as a result of the cost of medical care. This is bad, but is not as bad as the fact that they could no longer receive medical care. Wingard tells the reporter that "My hair hadn't even grown back from chemo, and I couldn't see my oncologist." After all, the doctors and hospitals want to be paid. In response to pressure from breast cancer advocacy groups, North Carolina had passed a law that temporarily granted Medicaid to breast cancer patients like Ms. Wingard. But then it ran out. As did her money. And her medical treatment. And her credit score plummeted.

What is the worst part of this story? For Ms. Wingard, it is both that she is broke and has no credit, and that she can no longer get treatment for her cancer. For many of the rest of us, it may be that something like that could happen to us or someone we love. For all of us, it is the remarkable fact that we find it unremarkable, that someone could go broke from their medical bills and lose their ability to buy necessary things on credit, and then not even be able to get their needed medical care. It is just the way it is, we think. Awful, and it happens all the time.

Except it is not just the “way it is”. Only here. It is not this way in any other wealthy, or most middle-income, countries. They all have universal health insurance that covers everyone for medically necessary care. Mostly they have had it for many decades. What is remarkable to most people in those countries is that we could possibly think that such a thing is unremarkable, if not exactly “OK”, is the “way it is”, and we are willing to tolerate it. This was the message from the PBS documentary by T. R. Reid “Sick Around the World”, aired in 2008, and covered by me, along with its 2009 follow-up “Sick Around America”, in ‘"Sick Around America": A little bit sickening’, August 5, 2009. In the earlier show, Reid interviews political and health leaders in 6 countries and asks, among other things, how many people in their country go bankrupt from medical debt. In that post, I quote the then-president of Switzerland, ‘a conservative who had originally opposed the Swiss program in the early 90s. “No one,” he boomed in his French-accented English, “why, it would be a national scandal!”‘ Then, and now as we approach the end of 2022, it should be one in the US, and yet we get stories like those of Ms. Wingard. These issues affect many Americans, and as usual are worst for those who are most disadvantaged.

It is “the way it is” in the US because we have chosen to make it so. Actually, it is our politicians who have chosen to make it so, blocking any effort to implement a universal health insurance program, from the 1920s to the time of Harry Truman in the late 1940s (when the AMA was the big opponent), to the 1960s when Medicare and Medicaid were passed and seen as the forerunners of such a program, to the current day. Why? Because of the powerful interests of those who are making money off our current health system, insurance companies and hospitals and other delivery systems (often vertically integrated) and pharmaceutical and device makers, who give lots of money to politicians and wield a lot of clout. They are not only making lots of money in an ostensible “free market” system, but in particular from government programs that they collect public money from. Don’t buy the false idea that “privatization” reduces costs; “administrative costs” are <3% in traditional “government” Medicare but upwards of 15-20% in Medicare Advantage. What privatization does is increase profit!

And, not content with making a lot from Medicare Advantage (a private, for-profit operation that our politicians should not allow to use the name “Medicare” – indeed, there is a bill in Congress now to prevent it – write your representative!), they further game the system by “upcoding”, paying folks whose job it is to make sure that every potential diagnosis and complication is recorded to maximize the amount of (your tax dollar) money that they collect from Medicare. Sometimes this is legal, if outrageous, but insurers are certainly not unwilling to push the legal envelope for more money (‘Cigna received millions of Medicare dollars based on invalid diagnoses, lawsuit claims’, ABC News October 17, 2022 -- and ‘millions’ is an underestimate). And it is assuredly not just Cigna that is guilty; while insurance premiums for Americans have increased 200% in the last decade, United HealthCare last year reported $24B ($24,000,000,000) in profit, more than ever before, an obscene amount, and a completely unabashed example of the fact that what is called the “healthcare” industry in the US is just an enormous profit center for the corporations that control it.

You want to know why we spend 2-3 times as much as any other wealthy country on “healthcare” and yet have so much poorer outcomes, shorter life expectancy, greater infant mortality, higher rates of “deaths of despair”? (‘Mirror, Mirror 2021: Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries’, Commonwealth Fund). This is the reason: the money is going to corporate profit, not your health care! If it were going to your healthcare, our outcomes would be better. But then they would not be making so much money, and donating so much of it to our (or maybe it is “their”) politicians.

Oh, maybe you thought that was the end. That insurance companies are raising our premiums, denying needed healthcare to sick people, making billions of dollars in profit, and corrupting our political system to ensure that it continues, was bad enough. And convincing you to shrug your shoulders and think “it’s sad, but that’s the way it is” when someone gets very sick, maybe dies, and goes bankrupt in the process. But, you know, that’s not enough for them. There is one more step: convincing you – and probably more important, the politicians – that it is not their fault that US health care costs so much. It is not the $24B in profit made by United. It is not the scamming of Medicare done by Cigna, or the entire Medicare Advantage and Direct Contracting Entities (DCE) programs that funnel public money into their pockets. No, no, it is YOU! As Wendell Potter, a “reformed’ health insurance executive, reports in ‘Corporate health insurance consultants blame high medical costs on our "bad habits" and "overuse" of system’ they say it is OUR fault for using too much care. Like, you know, going to the emergency room with chest pain, and sometimes it isn’t a heart attack (bad you!). Or, like Ms. Wingard, wanting to be treated for cancer. Or maybe even going to the emergency room when we are only sick, not dying, because we can’t get an appointment for the doctor.

It's not true, by the way. Europeans are hospitalized more frequently, have longer lengths of stay, and use the doctors at least as often. Their outcomes are better, especially when the health of the entire society is considered (we have a way of fudging this by only considering those people who were actually able to get care), and they pay a lot less. No, it is the profit and “administrative costs” of the health insurance companies and healthcare corporations.

Apparently buying into the idea of “incrementalism”, our politicians for the last 60 years have given us limited programs to help limited groups of people, at least somewhat. Seniors, disabled people, sometimes children, sometimes programs like the North Carolina one that paid for Ms. Wingard’s cancer treatment specifically because it was breast cancer (until, of course, it didn’t). This is NOT the way to go to get universal health care. The ACA (Obamacare) included the option for states to expand Medicaid to the less-than-desperately-poor and some did and folks in the other states are getting sick and dying.

No. We need a universal, comprehensive, EVERYBODY in, NOBODY out, health insurance system, government run or tightly regulated so there are not obscene profits. Like improved and expanded Medicare for All. Now.

 

Mirror on the Wall: Commonwealth Fund report continues to show US has poor outcomes at high cost

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On December 5, 2008, I commented on the data from the 2008 Commonwealth Fund report comparing health status in a number of countries (Not Getting What We Pay For). The US fared very poorly on that study. The Commonwealth Fund has just released its 2010 study “Mirror, Mirror on the Wall” (Commonwealth Fund executive summary, Commonwealth Fund full report) and the news is no better. In comparing 7 industrialized countries (Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States), the US is #1 in health expenditures per capita at $7,290, 87% higher than second-place Canada, over twice that of the average of the other 6 ($3354) and nearly 2.5 times as much as the UK. [“Expenditures shown in $US PPP (purchasing power parity)”.].

Distressingly, but unsurprisingly to those who pay any attention to the area, including having read this blog or having seen the 2006 or 2008 Commonwealth Fund reports, this expenditure does not lead to good performance on the study’s measures of Quality Care (comprised of Effective Care, Safe Care, Coordinated Care, and Patient-Centered Care), Access (comprised of Cost-related Problems and Timeliness of Care), Efficiency, and Equity, nor on the all-important health outcome “Long, Healthy, Productive Lives”. In fact, the US ranks last -- # 7 – on that outcome indicator. And while there is not one country that leads in all the categories – Australia, for example, ranks #3 overall, but is #1 in “Long, Healthy, Productive Lives”, and is tied with the US for last in “Access”; the UK, while #6 on “Long, Healthy, Productive Lives”, is #2 overall (behind the Netherlands) despite spending the 2nd lowest amount (to New Zealand’s lowest) per capita, and ranks #1 or #2 on 6 of 10 criteria, and #7 on only Patient-centered care.

The US ranks very poorly, as it did in 2008, on Efficiency, which is interesting. We can more easily understand low rankings in Access and Equity, given our completely inequitable system of funding and access, but poor Efficiency scores reflect our poor communication, with tests often being repeated because information is not carried forward, patients being readmitted, and a variety of other characteristics. There are 8 subcategories comprising Efficiency, and the US ranks #6 on 4 and #7 on 4 (and for the whole category).

Of course, this kind of report doesn’t seem to affect policy makers too much. We already knew this, and the health reform process was in part an attempt to address it, but the current bill, PPACA, certainly doesn’t do enough. Some of the additional funding that is targeted to public health will make a difference, but it is clear from the debate in Congress that there are many who simply do not support improving the health of the American people if doing so will require cuts to the profits of the big healthcare industries who contribute large sums to them.

Some critics of the Commonwealth Fund report, such as Dr. Richard Cooper of the University of Pennsylvania, have stated that the problem in the US is not that that we have a health system which is overbuilt on the high-tech, high-cost specialty end rather than on primary care, but rather that we have more poor people; he provides evidence that, on a large regional basis, areas of the country with more poor people (e.g., the Southeast) have worse health status than those with fewer poor people (e.g., the upper Midwest). There can be no doubt that poor health status is tied to low socioeconomic status, and that the large number of poor in the US is in significant part responsible for the poor health system performance identified by the Commonwealth report and others. However, as I and many others have pointed out in the past (Public Health and Changing People's Minds, May 15,2010; Poverty, Primary Care and the Cost of Medical Care, Feb 18, 2010; Health is more than Medical Care, Jan 27, 2010), health is not simply a result of the health care, or medical care, system. The other countries measured in the Commonwealth Fund report do not have a lower percentage of poor people by chance or luck; they are, to greater or lesser extents, social democracies with policies that ensure that their people have housing, food, and education. There are poor people in those countries, but their most basic needs are ensured and this goes a very long way to decreasing their health risk. Public health, medical professionals and others in those countries are well aware – expert in – the social and socioeconomic needs of the poor in their societies, but the situation of those people, is significantly improved, to a much greater degree than in the US by a much more extensive safety net.

Poverty is bad for your health, and programs that help ameliorate the impact of poverty improve the health of populations. In addition, the presence of adequate health care services, especially primary care services, further enhances outcomes. It is not an either/or choice. Shi and colleagues demonstrated that the increased infant mortality and low birthweight rates in poor communities are virtually eliminated by a higher primary care presence.[1]

The data provided by the Commonwealth Fund should be embarrassing to every policy maker, every person of influence, and every citizen of the US. It is incontrovertible data that demonstrates yet once again that the issue is not that we aren’t spending enough money, but is the way that the money is spent: We spend it in ways that make our health status poor and our health corporations wealthy. There should be no tension between increasing primary care, increasing public health and prevention, and providing the core needs of people for food, housing, education, and work. They are all components of a society that is not only basically decent, but which is concerned about its future, the health of its people, and its workforce. What we clearly do not need, however, is to continue to spend money in the way that we are on high-tech subspecialty care that benefits few patients and often not for very long. Indeed we need to spend much less, and use the money where it will have a positive impact.

Maybe by 2012 the Commonwealth Fund will show the US making some progress. I hope so, but it is going to take some serious structural changes.

[1] Shi L, Macinko J, Starfield B, Xu J, Regan J, Politzer R and Wulu J, “Primary care, infant mortality, and low birthweight in the states of the USA”,J Epidemiol Community Health 2004;58;374-380.