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.

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.

 

Why can't the US have health coverage for everyone? We CAN!

Every other wealthy country in the world has long since figured out how to provide health coverage to its entire population. Every one. And yet this is still controversial in the United States, as continues to be illustrated by the recent Democratic debates.

Every one of those Organization for Economic Cooperation and Development (OECD) countries has better health outcomes than the US as result of covering everyone. The health outcomes are not always terrific, but better, as a population, than ours. There are two components to how healthcare is provided; one is how it is distributed (very inequitably in the US and much more equitably in the other countries) and how well it is funded. The second might depend upon a nation’s resources, the first upon its values. Some of these other countries should, and could, increase their health funding (e.g., Canada) but the fact remains that they are doing better because they distribute it better. And, even when well-funded, a national health plan costs less – far less, in every other country – than we spend in the US.

So we have the money, and we are ostensibly spending it on health care. Indeed, if we count not only the direct public expenditures by governments (federal, state, local) for their employees and for Medicare and Medicaid and S-CHIP and other programs, but also the income foregone by government because the health insurance premiums paid by employers (although not by employees) are tax-exempt, it is about 60% of our health expenditures. In other words the US spends more PUBLIC money than other countries spend altogether. Another way of thinking about it is that we are paying for a national health program but not getting it.

So why does this continue to be controversial? Why do the majority of Democratic presidential candidates not support it? Why do there continue to be questions from moderators at the last debate asking Sen. Sanders how much it would cost and how it would be paid for? One possible answer is that these candidates and questioners are ignorant of the facts, and ignore those repeated time and time again by both Sen. Sanders and Sen. Warren, explaining that we are already spending more than it would cost for Medicare for All. The other possibility is that it is part of a concerted campaign to obfuscate and lie about the issue to protect wealthy and powerful interests.

Let us start with the first. Maybe they are just ignorant of the facts, or maybe they are too stupid to understand them (I doubt that). Sanders responded to a questioner that the cost of a national health insurance system, Medicare for All, that covers everyone in the US for everything (including things that we don’t get now with most health insurances, like hearing aids and glasses ), with no out-of-pocket costs for co-pays or deductibles, will cost less than we are currently spending. This is made possible by re-directing those dollars currently being ostensibly spent on health care and actually spending them on health care, rather than on administrative costs and profit for health insurance companies, pharmaceutical companies, and some big health care providers. A new article in the Annals of Internal Medicine, “Health Care Administrative Costs in the United States and Canada,

2017” by Himmelstein, Campbell, and Woolhandler (Ann Intern Med. doi:10.7326/M19-2818, online publication January 7, 2020), shows that:

U.S. insurers and providers spent $812 billion on administration, amounting to $2497 per capita (34.2% of national health expenditures) versus $551 per capita (17.0%) in Canada: $844 versus $146 on insurers' overhead; $933 versus $196 for hospital administration; $255 versus $123 for nursing home, home care, and hospice administration; and $465 versus $87 for physicians' insurance-related costs.

This represents 31% of all US health care costs, twice the rate of administrative costs in Canada. Since they excluded some areas that are accounted for differently in Canada, it is likely an underestimate. They add that “Of the 3.2-percentage point increase in administration's share of U.S. health expenditures since 1999, 2.4 percentage points was due to growth in private insurers' overhead, mostly because of high overhead in their Medicare and Medicaid managed-care plans.” These are the Medicare (and Medicaid) managed-care plans that the Trump administration lauds as the best part of Medicare, as I noted in a quote from CMS administrator Seema Verma in “Scamming Medicare: It's the providers and insurers, not the patients!” on December 22, 2019. Another very recent piece, a systematic review of studies on the cost and financing of single-payer health care in the US, “Projected costs of single-payer healthcare financing in the United States: A systematic review of economic analyses” published in PLOS One by Cai, et al. “found a high degree of analytic consensus for the fiscal feasibility of a single-payer approach in the US.” (PLOS Medicine | https://doi.org/10.1371/journal.pmed.1003013 January 15, 2020).

So the other explanation, the more likely explanation since these people are not, in fact, stupid and probably not at this point ignorant, is willfully ignoring the facts because they threaten a status quo that is extremely lucrative for a lot of big companies, insurance companies and pharmaceutical companies especially, and a lot of big providers, hospitals and health systems. (This includes those that are ostensibly “non-profit”, which means that they don’t pay shareholders – and don’t pay taxes! – but doesn’t keep them from making lots of money which they invest back into the services that will make them more money – e.g., orthopedics, cardiology, cancer, ICUs -- rather than those the community as a whole really needs but are not money makers – e.g., mental health, primary care, etc. -- and paying their C-suite executives salaries in the millions!) These companies are absolutely not interested in losing this money, and they are big contributors to politicians.

This is abetted, indeed stimulated, by a tremendous disinformation campaign by insurance companies, following upon the model developed by car companies and cigarette manufacturers. The most obvious is the perversion of the language of “choice”, exposed by former health insurance executive Wendell Potter in the New York Times on January 14, 2020. When they say “choice” they mean choice of insurance plan. In addition to the fact that most Americans are limited to a choice between one or two plans that their employer offers, people don’t care about choosing their insurance company (“I’m an Aetna guy!” “I love CIGNA!”); they care about choosing their doctors and other providers and hospitals – the very things that the private health insurance industry restricts!

But could we not, somehow, keep private insurance as an option, as suggested by most of the Democratic candidates and pundits? A qualified yes. In countries that do this, say Switzerland, there are private insurance companies but they are highly regulated. ALL have to provide the SAME coverage and ALL have to charge the SAME price. How do they compete? Wait for it -- on customer service!! Are US insurance companies ready to do this?

To a disturbing degree, people are swayed by these lies. Sometimes you hear the myth that goes something like “Americans don’t have a sense of social responsibility like people in ‘X’ do”, but they do. As Cai points out, “Public support for provision of universal health coverage through a plan like Medicare for All is as high as 70%, but falls when costs are emphasized,” even though almost all Americans would pay less for much more – and critically, all Americans would be covered. What is unacceptable is that the “responsible” media and (hopefully, if we’re going to vote for them) “responsible” politicians, in the debates and in their coverage, repeat these lies.

We also sometimes hear the question “what will all those people who work for insurance companies do if they are closed down?” It is a legitimate one, and one for which the Medicare for All bills prescribe retraining, but the real issue is why is this asked only for this industry and never about workers who lose their jobs because companies relocate their manufacturing and services overseas? Why is the cost never an issue when we are talking about military expenditures (not for pay for personnel, no, but for incredibly expensive and profitable armaments), but only when we are talking about people’s health?

Americans as a whole pay a huge amount for health care, in premiums paid by individuals and their employers, in tax dollars for Medicare and Medicaid, and in out-of-pocket co-pays, deductibles, and huge drug costs. What we get are some people with good coverage, most people with mediocre coverage, and a lot of people with poor or no coverage. Every "scandal" about someone getting a $100,000 bill from an out-of-network doctor at an in-network hospital, about a $30,000 / month medication, about denial of necessary care, is not fluke but a built-in part of our crazy non-system.  Medicare for All, as in the Sanders Senate bill (S.1129) and the Jayapal House bill (HR.1384) will cover EVERYONE for EVERYTHING.

Let’s do it. Now. And let’s have our media and politicians stop repeating the insurance-company funded lies about it.