Consumer experiences with health insurers: Not always good

I have often written about the particular burdens that people with no health insurance have accessing adequate healthcare. However, these problems affect Americans with health insurance as well. To look more into the experience of insured Americans, the Kaiser Family Foundation (KFF) did an extensive poll on consumer experiences with health care insurance to understand

how health insurance works involves exploring how people feel about their health coverage, how affordable that coverage is, how they interact with their insurance provider, the problems they experience, and, critically, how insurance works for people when they get sick.

The findings often seem to be in conflict, but this is largely because different people are experiencing different things. For example, 81% of people surveyed (91% of those with Medicare) rated their insurance as “excellent” or “good”, but for those who described their own health as fair or poor, that satisfaction was down to 68% (still a large majority, but a lot lower). This is to be expected; insurance in general is something you hope to not use, and when things are going well and you don’t need it, it functions well (except for those premiums). When you have not had a fire in your house, or a car wreck, or a close relative die, your homeowner’s, automobile, or life insurance are working just fine. What matters is how they function when you have a need. And health insurance is different from other forms of insurance because, for a bunch of bizarre historical reasons, it is the common, routine and accepted method of paying for your health care, not something you buy hoping to never have to use like other insurances. And, yet, when you get sick, and need hospitalization, surgery, cancer treatment, etc., is when the rubber meets the road, and why sicker people are less satisfied.

Let’s spend a little more time with this. It doesn’t matter much if you are happy with your health insurance when you are well if it is not going to serve you when you need it.  While that could be never, it is unlikely; if you are young and healthy, you will get old – or get sick sooner. If you are middle-aged or older and are healthy, terrific – until you are not. You may ‘not have been sick a day in your life’, and that is good, but then one day, you find out you have cancer. Or are in a car wreck. Or a pretty-well-controlled chronic condition gets out of control. Being concerned about the minority of people and their health and insurance coverage is not just a matter of social responsibility (although that is important) because there is a great likelihood you will be too, one day. Maybe not soon. Or maybe soon.

 Remember also that, although this poll (and others) are one-time snapshots, the group of people who are sick is not static. Over time (say looking at it each year), some people who used to be in that group leave it – either through recovery or death. Others join it. This is how the magic of consultants work – hire us and the 1000 most costly people you had last year will cost you, as a group, less this year. Of course.

Going beyond this issue, the KFF poll found other seemingly contradictory information. Despite expressing a high degree of satisfaction with their health insurance, people also identified a lot of problems.

A majority of insured adults (58%) say they have experienced a problem using their health insurance in the past 12 months – such as denied claims, provider network problems, and pre-authorization problems.

Unsurprisingly, this rate was higher (about 2/3) among sick people, but was still well over half of those in good health. And, furthermore, only half of those who had problems with their insurance were able to resolve those problems to their satisfaction; a significant number of folks simply did not get the health care that they need. And these problems were even worse among some groups of people, such as those with mental health problems.

 

Trying to understand these seemingly contradictory findings can be hard, but clearly some horrible psychological factor is present which allows the American people to think something is “good” when it is not because their expectations have been so diminished. It is likely that some of this is “well, it’s not as bad as I was afraid it might be” or “it’s not as bad as what happened to my neighbor or cousin”. If you set the bar low enough, a lot of bad can pass over it. Note that the cycle of bad that affects Medicaid recipients even more than others – poverty makes illness greater, and makes it harder to get treatment and to recover, and illness increases poverty. To be “satisfied” with your health insurance should not require you to be without healthcare needs!

Good healthcare is something quite different. It is getting all the care you need (and none of the care you don’t need) promptly, efficiently, courteously, and affordably. It should not require long waits to get into see a clinician or to get into a hospital. There should be adequate staffing, both of medical professionals such as doctors and nurses and other staff necessary. There should be no out-of-pocket cost for medical services (or a very minimal one which can be waived for the poor). It should be paid for proactively by “social insurance” (such as traditional Medicare) and adequately funded for 100% of the cost (unlike, currently, traditional Medicare). This does not mean the wealthy should not pay more, but they should do so through higher taxes to support this health system, not when they are ill. The randomness of “you pay today because you got sick or injured, I don’t (until, maybe tomorrow, when I am)” should be abandoned.

Standards for approved drugs and procedures should be established by independent scientific panels whose members are forbidden from taking corporate dollars. Such standards may be more or less restrictive, but must be applied equitably to everyone regardless of where they live or their ability to pay. Inequity has no place in healthcare.

And, of course, all profit-making must be eliminated. This means from both for-profit and ostensibly non-profit hospitals and other healthcare facilities like long-term care, insurance companies, device and drug manufacturers, and other parasitic leeches. Indeed, we could keep private insurance companies, provided they are adequately regulated – i.e., they must provide all the same benefits and must charge the same amount and not be permitted to make a profit. This would require them to compete on the only legitimate factor, customer service. Let the ones who don’t do a good job go out of business. This is more or less the Swiss model. There are several potential models, but all must include financial and service equity for all.

They should not be about being happy with your insurance because you didn’t get sick, or because they screwed you less than you feared they might!

If you want a little laugh, read this by Kendra Allenby from the New Yorker. But somehow, if you have ever been in the hospital, I don’t think you’ll laugh too hard because it will be too familiar.

Doctors, patients, corporatization, and moral crisis

In the last few years a fair amount has been published, especially in the medical media, about physician burnout. This term includes everything from frustration, to saying they would not encourage their children to become doctors, to leaving the profession or retiring early, to, in extreme but sadly not rare cases, suicide. The emphasis has usually been on the amount of work that the doctors have to do, the stress of new technologies such as the “electronic medical record” that, rather than simplifying things or making them more efficient, mainly create much more time-consuming work, and the ever-present threat of malpractice suits and other litigation against them. Recently, the NY Times Magazine, in “The Moral Crisis of American Doctors” by Eyal Press (June 15, 2023), presents more balanced and accurate coverage.

The article discusses the work of Wendy Dean, a psychiatrist and administrator at the US Army research center. Dr. Dean was shocked to learn that the rate of suicide in physicians was higher than that of the active-duty military.

The doctors Dean surveyed were deeply committed to the medical profession. But many of them were frustrated and unhappy, she sensed, not because they were burned out from working too hard but because the health care system made it so difficult to care for their patients.

Dr. Dean thought about this issue in terms of “moral injury”, generally thought to affect those who participated in or observed horrible violations of their moral compass in war, such as the murder of civilians.

Doctors on the front lines of America’s profit-driven health care system were also susceptible to such wounds, Dean and [her co-worker] Talbot submitted, as the demands of administrators, hospital executives and insurers forced them to stray from the ethical principles that were supposed to govern their profession. The pull of these forces left many doctors anguished and distraught, caught between the Hippocratic oath and “the realities of making a profit from people at their sickest and most vulnerable.”

The article goes on at length, comparing the doctors to assembly-line workers who fear for their jobs if they speak out, to non-compete and non-disclosure agreements they are forced to sign, to the way that this manifests in particular specialties, such as Emergency Medicine.

This piece gets to the heart of the matter more than almost anything that has been published in the mainstream media. I would summarize the lesson as: The pursuit of profit is dangerous to your health. The transformation of medical care from control by doctors to control by accountants and venture capitalists means that something other than what is best for the health of people, as individuals and as a population, is the primary consideration driving the structure and implementation of health care. It is not a pretty picture. Yes, doctors make and have always made mistakes. Yes, doctor have often been avaricious themselves. Yes, sometimes people have been hurt or died from unnecessary procedures. But at least in theory most doctors believed that what they were doing was for the best interests of their patients.

We have moved beyond (or backward from) that. We have entered an era in which an assembly-line mentality has been implemented in American healthcare, when doctors and other healthcare workers are seen as replaceable cogs, when the provision of healthcare is, like selling cars or liquor or financial instruments, not mainly about the “product” but is just a vehicle for generating money for its owners and managers. Tough luck, all you “burned out” doctors, probably suffering from moral injury. Tough luck, sick people.

This has been a long time coming. The deprofessionalization of medicine should have been predictable decades ago, and it was. In a recent blog post (Private equity, private profit, Medicare and your health: They are incompatible, May 11, 2023) I cite two books. “American Health Empire” (1971) by Barbara and John Ehrenreich and other members of the HealthPAC collective, showed how even then hospitals and health systems were being corporatized. Paul Starr’s 1982 book “The Social Transformation of American Medicine” focused on the impact of this on the professional role of physicians.

Another huge warning signal was, or should have been, the explosion of the space shuttle Challenger on January 28, 1986. As reported at the time and in multiple more recent articles (e.g., Engineer Who Opposed Challenger Launch Offers Personal Look at Tragedy, and Remembering Roger Boisjoly: He Tried To Stop Shuttle Challenger Launch, both from 2012), engineers for the Morton Thiokol corporation knew that there was a problem with key pieces of the shuttle (the infamous “O-rings”), and had been ignored by their bosses when they called attention to it. And never went public with it for fear of losing their livelihoods. Until after the disaster. At the time, it was noted often how this conflicted with the codes of ethics of the engineering profession. But engineers were no longer self-employed independent professionals; they were employees of huge profit-seeking corporations. Many of us who were doctors pointed to this, saying this trend was not limited to engineering, but was happening to other professions, including medicine. It had not yet progressed that far, but was fast moving down that track.

Independent physician practice, solo or group, single or multi-specialty, had begun to disappear, as practices were acquired by larger companies. Sometimes these were physician-owned, and seemed to continue to carry the same “old” values. But then they were bought out by hospitals, health systems and private investors. So were the hospitals. We got a lot of glitz -- fountains and art work in our entry halls and fancy new machines, and investment in our practices, particularly those “product lines” that had the greatest “return on investment” measured, of course, in dollars and not human health. How could we, as ethical medical professionals, buy into the casual use of such terms as “product lines” and “return on investment” when talking about the health of our patients?

Some of the explanation is greed, and some of it is psychological, as doctor began to think that using corporate-speak meant that they were cool, and allowed them to hobnob with the real power players in control of the industry. Many doctors obtained MBAs.  And now some of them are very rich. Some are even CEOs. It’s not surprising that doctors can be smart enough to achieve this, or that they can be as susceptible to the lure of power and money as anyone else. It also does not mean that all doctors who get MBAs use it to limit care in order for their company to make more money. But that does not make it good for the people of the nation. And it can, and often does, create another moral conflict, perhaps even moral crisis.

Another recent piece, by the Reverend William Barber and Gregg Gonsalves in The Guardian, “The fourth leading cause of death in the US? Cumulative poverty”, is scarcely unrelated, although rather than focusing on physicians it focuses on patients (the medical term for “people”). It clearly and thoroughly documents the impact that poverty has upon health. And while the poor are the tip of the iceberg, the most vulnerable, the cutbacks on care that come from megalomaniacal pursuit of money affects much larger parts of the population.

Because we have a healthcare system that is designed to make money for the corporate entities that control it, that system does not deliver quality care to many (or most) people. As a result it creates unfulfilling, stressful, and sometimes intolerable working conditions for its employees, including physicians. Moreover, in the classic “divide and conquer” technique long used by those in control, it leads to people being angry at their doctors for the frustrations and denials that they experience, which they mistakenly believe the doctors control. The denials of care are made by the insurance companies that they have (and often choose, such as Medicare Advantage). The long delays for getting appointments and the inadequate time physicians spend listening is the result of the management of the health systems that employ them, not only treating doctors as assembly-line workers but patients as widgets to be produced. If it seems impersonal and uncaring, it is.

So what is to be done? Doctors can start by demanding that their professional organizations, beginning with the AMA, condemn and resist this corporate transformation. They also must recognize that they are no longer independent practitioners, but employees, just as the Morton Thiokol engineers were, and that the greatest protection that they – and their patients – have is unionization. You, doctors, may be well-paid workers, but you are workers! Unions can educate people, their members and the public, about how the power is actually distributed and who is calling the shots. Other people can respond by contacting their political representatives and demanding that the power and authority of private corporations over their health care be drastically curbed; this includes insurance companies and health-care companies. A great first step would be to repeatedly demand that every representative and senator, every state legislator, sign on to support a universal health insurance system, such as Medicare for All.

There will still be plenty to do after that, but it would provide a structure for making things better.

Where has all the caution gone? COVID infection is still common!

Most infections diseases in people get passed from one person to another, although sometimes animals and insects are the vectors. More rarely (as in the case of COVID-19) an ‘enzootic’ infection (one that resides in animals) can ‘make the jump’ to people, although after that the transmission continues to be primarily person-to-person. If there is an outbreak of an infection it can spread rapidly among ‘susceptibles’ (people who do not have immunity through either prior exposure to the infection or from vaccination against it), particularly in crowded conditions.

Many of us are aware of this from our children. In winter, young children in school and day-care bring home infections that can make them sick and often infect other members of the family. Luckily, most of these are minor and transient (the ‘common cold’), but in the past included many serious and potentially fatal diseases such as polio, measles, mumps, whooping cough, rubella, diphtheria, Hemophilus influenza, chickenpox, and others. The frequency of these diseases has gone down dramatically as a result of vaccines that have been incredibly effective. Outbreaks still occur in places and populations where an insufficient percent of the children have been vaccinated to result in ‘herd immunity’. In the US, this is, sadly, most common not in communities which do not have access to vaccinations, but in which large numbers of people have, for whatever their reasons, chosen to forego vaccination for their children.

 

Dave Caverly, Speedbumps

 

The way that outbreaks of any infectious disease, from colds to influenza to chickenpox to sexually-acquired infections to COVID-19, occurs depends upon the route through which that organism is transmitted – sometimes by respiratory droplets (cold, COVID, pneumonic plague, polio), sometimes through fecal-oral contamination (think young children), sometimes through sexual contact involving exposure to blood or other body fluids, sometimes by more than one of these. Respiratory transmission is particularly great in crowded indoor environments, such as schools, concerts, restaurants, clubs, and family gatherings. And gyms, where people working out are breathing heavily. And singing (such as the karaoke sessions enjoyed by the NY State judges before many came down with COVID). Sexual transmission is, of course, less likely to be incidental and requires close and often prolonged contact.

But there is a similarity. This is that we are at risk for exposure not only from symptomatic individuals with whom we have contact, but often from those who are not, or not yet, symptomatic but who have been infected by someone else. In the case of sexually acquired infections, the idea that when you have sex with someone you are not only having sex with them, but potentially anyone else they have had sex with, or the people those people had sex with. Monogamy, is of course, protective, provided, of course, that it is actually practiced. It does not necessarily take many outside episodes to introduce an infectious disease.

In the case of COVID, we are not talking about sex, but about high-risk exposures. And also about what we assume should have been low-risk exposures but were to people who themselves may have taken greater risks. You may be pretty careful, not go out much, wear your mask if you are indoors with groups of people that you do not know, but be less careful if you are with close family members, especially those in your home. But just as a child can bring home a cold from daycare, or a sexual partner can bring home an STI from a relationship that you did not know they had, a family member can bring home COVID from a concert, club, restaurant, airport, social gathering, or other event in which others, who you (and maybe they) do not know were infected, unvaccinated, unmasked. If you happen to be more vulnerable: older, sicker, immunocompromised, and especially (because this is usually fixable) unvaccinated, the outcome can be not just infection but hospitalization and even death.

Minority communities have higher rates of all of these problems – infection, hospitalization, and death. Some of this can be tied to greater prevalence of chronic disease, some could possibly be lower rates of vaccination, and much may be related to having a higher rate of low-income and jobs that require actual presence and cannot be done from home by ‘Zooming it in’. It can also be true that poorer families may be more likely to have multiple generations living in the home, with various sources of infection (school, work, social activities) increasing the likelihood of COVID being brought into the home and infecting family members who are more at-risk.

Most of us want to see and interact with our family members. But if those family members have contracted infection, whether by “choice” (adopting higher-risk behaviors, not wearing masks, especially not being vaccinated) or by bad luck despite taking precautions, seeing them puts us at greater risk. Some of that risk may be unavoidable, but some can definitely be mitigated. COVID is NOT gone, but people are taking more and more risks, including me. I returned from a trip to Europe a few days ago, and while I wore an N-95 mask on the plane and in the airports, it was risky (the line for passport check in the Madrid airport crowded despite ironic signs on the floor asking people to maintain a 2-meter distance, between which were many people, was surely a potential super-spreader event). But I seem to be one of the few people worried about it. In the gym, no one else is wearing a mask, even as they huff and puff on machines which definitely increases the likelihood of spread, and I take no reassurance from their carefully wiping them down, since this is not really how COVID is spread. The front desk has even taken down the plastic barrier that has long been in place.

If all this were occurring because the rate of infections, and thus hospitalization and death, were down, this could be a good sign. Unfortunately, it is not. A recent headline in my local paper, the Arizona Star, on June 3, 2022 is “AZ COVID numbers continue to rise”, and daily published an update on number of cases. Yes, vaccination has definitely reduced the rate of hospitalization and death among those who have been infected, but the greater the number of infections the greater the risk of those really bad outcomes.

Death is now less likely, at least among the vaccinated. Be vaccinated. But COVID is still there, and in many places cases are increasing. Continue to exercise caution, and try to not take unnecessary risks.