Insurance Companies: A Major Problem in America's Health Care

Having gone through proton therapy and been on an expensive medication myself during the last year, I know first hand the problems most Americans face when seeking medical treatment.  One of the biggest is the effort by insurance companies to deny coverage and/or restrict permitted medications for the simple purpose of reducing payouts. The companies that happily take your premium payments simply do not want to have to pay out claims when their insureds need medical care or expensive medications.  In my own case, everything was eventually covered after protracted confrontations with my prescription insurance carrier.  Many are not so lucky and the reality is that most of us find non-medical personnel trying to dictate our medical care.  An op-ed in the Washington Post looks at this problem which, to me, is the reason a private for profit health insurance system without a significant challenge of a public option will never best serve individuals' and families' needs.  Here are column excerpts:

We know how important it is to have insurance so that we can get health care. As a physician, parent and patient, I cannot overemphasize that having insurance is not enough.

As a gastroenterologist, I often prescribe expensive medications or tests for my patients. But for insurance companies to cover those treatments, I must submit a “prior authorization” to the companies, and it can take days or weeks to hear back.

Because it ends up with the desired outcome, you might think this is reasonable. It’s not. On most occasions the “peer” reviewer is unqualified to make an assessment about the specific services. They usually have minimal or incorrect information about the patient. Not one has examined or spoken with the patient, as I have. None of them have a long-term relationship with the patient and family, as I have.

The insurance company will say this system makes sure patients get the right medications. It doesn’t. It exists so that many patients will fail to get the medications they need.

I’ve dealt with this system from the patient side, as well. My daughter has a rare genetic disorder . . . She receives applied behavior analysis therapy, an approach often used for autism, and which has been wildly successful in improving her skills and communication. But recently, our health insurer reduced the amount of therapy they thought she needed.

I probably have better access than almost anyone else can get, yet the ability of my daughter’s providers to mitigate denials for services they deem appropriate is slow and often ineffective.

My daughter can languish for months or years not receiving care that every highly qualified person who treats her agrees she needs. While we wait, the window to give her a little bit more function, a little bit less suffering and a little better life gets smaller.

Consumers have a right to appeal denials for health-care services, but regulations still largely focus on the process, not the content. For instance, insurers are required to notify you in writing of a denial, and patients have the right to an internal appeal; if that fails, some states also allow for an external review.

Insurance companies know that many patients don’t bother to appeal at all. A smaller fraction ask for an internal review, and still fewer seek or even know about external review options available in most states. Of the cases that do end up under external review, almost a third of all insurer denials are overturned. This is clear proof that whatever process insurers have to determine medical necessity is often not in line with medical opinion. A study of emergency room visits found that when one insurance company denied visits as being “not emergencies,” more than 85 percent of them met a “prudent layperson” standard for coverage.

This is a system that saves insurance companies money by reflexively denying medical care that has been determined necessary by a physician. And it should come as no surprise that denials have a disproportionate effect on vulnerable patient populations, such as sexual-minority youths and cancer patients.

When an insurance company reflexively denies care and then makes it difficult to appeal that denial, it is making health-care decisions for patients. In other words, insurance officials are practicing medicine without accepting the professional, personal or legal liability that comes with the territory.

We don’t have to put up with this. Health care in the United States is shockingly opaque; it’s time to take insurance companies out of our decision-making process.

America's Flawed Health Care System Fuels the Opioid Epidemic

I will be honest right up front.  I fully support a single payer health care system that would put healthcare insurance companies as we know them out of business.  Having done legal work for a hospital system and physicians in the past, the former, like health insurers, care only on maximizing profits despite advertisements to the contrary, while the latter are largely restricted in the practices by what health insurers will pay.  Prescribing a pill to mask the symptom is so much cheaper than addressing the true under lying cause.  And, of course, the insurers care nothing about a preventative approach to medicine.  Put all of this in the context of the opioid crisis in America and there's a reason why other advanced industrialized nations are not experiencing a similar crisis: they have universal health care systems that take an entirely different approach to health care.  America's health care system is literally killing tens of thousands of citizens.  A piece in the Washington Post looks at this reality - something that neither Trump or Congressional Republicans will admit, much less address.  Here are article highlights:

For the second year in a row, life expectancy in the United States has dropped.

It is not hard to understand why: In 2016, there was a 21 percent rise in the number of deaths caused by drug overdoses, with opioids causing two-thirds of them. Last year, the opioid epidemic killed 42,000 people, more than died of AIDS in any year at the height of the crisis.

“We should take it very seriously,” Bob Anderson, chief of the Mortality Statistics Branch at the National Center for Health Statistics, told my colleagues Lenny Bernstein and Christopher Ingraham. “If you look at the other developed countries in the world, they’re not seeing this kind of thing. Life expectancy is going up.”

In other words: In no other developed country are people taking and dying from opioids at the rates they are in the United States. We have about 4 percent of the world's population but about 27 percent of the world's drug-overdose deaths.

What explains the discrepancy?  The U.S. medical system.

Americans are prescribed opioids significantly more often than their counterparts in other countries. In the United States, 50,000 opioid doses are taken daily per every million residents. That is nearly 40 percent higher than the rate in Germany and Canada, and double the rate in Austria and Denmark. It is four times higher than in Britain, and six times higher than in France and Portugal.

That is in large part a result of our health insurance structure. Unlike countries that provide universal health care funded by state taxes, the United States has a mostly privatized system of care. And experts say insurers are much more likely to pay for a pill than physical therapy or repeat treatments. “Most insurance, especially for poor people, won't pay for anything but a pill,” Judith Feinberg of the West Virginia University School of Medicine told the BBC.  . . . . the best thing is physical therapy, but no one will pay for that. So doctors get very ready to pull out the prescription pad. . . . . . As a result, Americans were being prescribed opioids. Often, they were given several more pills than they could be expected to use, to avoid repeat visits. 

[D]octors in the United States are much more likely to provide painkillers than are doctors in other countries. One comparative study found that Japanese doctors treated acute pain with opioids about half the time. In the United States, the number was 97 percent of the time.

There are other culprits, too. The United States is one of only two countries that allow prescription drug companies to advertise on television. (The other is New Zealand.) The companies do advertise, a lot. In 2016, pharmaceutical companies spent $6.4 billion on advertising. Experts say, too, that U.S. medical schools have not done enough to educate students on pain management, addiction and opioid use and abuse.

Drug companies also try to woo physicians with gifts. Some companies host fancy dinners, and others sponsor conferences and junkets. In 2016, for example, OxyContin maker Purdue Pharma spent $7 million on gifts to doctors and teaching hospitals. . . . .  In the same period, the company doubled its sales force, distributing coupons so doctors could offer patients 30-day supplies of OxyContin and other highly addictive drugs. In those six years, prescriptions for OxyContin jumped from 670,000 to more than 6 million.

That alarmed at least one public-health group, which ran a 2009 bulletin titled, “The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy.”  By then, it was too late.

Health Insurers Trash Latest Senate GOP "Reform" Bill

Other than Congressional Republicans and the pathological liars at the White House, there seems to be little enthusiasm for the GOP's latest rob the poor to give tax breaks to the rich scheme which is once again dressed up as a pretend "reform" of America's health care system.  Opponents range from hospital associations - rural hospitals could literally be forced to close if the bill is enacted - to AARP which is galvanizing the elderly who (i) vote in high percentages, and (ii) worry a great deal about health care. Now joining the chorus of opponents even before the Congressional Budget Office releases its scoring net week are major health care insurance carriers. While obviously not the most reliable critics, these companies do have an interest in a program that will not bankrupt them or leave them as the villains when millions lose coverage.  A piece in Talking Points Memo looks at this new assault on an already horrendously bad proposal ( a copy of the letter from Blue Cross?Blue Shield is embedded in the article)   Here are excerpts:

Big players in the insurance industry, which has mostly held back public criticism of the GOP’s Obamacare repeal push, eviscerated a Sen. Ted Cruz (R-TX)-sponsored provision that was included in the latest version of the Senate legislation.

“It is simply unworkable in any form and would undermine protections for those with pre-existing medical conditions, increase premiums and lead to widespread terminations of coverage for people currently enrolled in the individual market,” Blue Cross Blue Shield and America’s Health Insurance Plans said Friday in a rare joint letter to Senate leaders.

The Cruz proposal, known as the “Consumer Freedom Option,” would allow insurers to sell plans that would be free of many Affordable Care Act mandates if they were also selling Obamacare-compliant plans.

Insurers and outside health experts had already been raising their concerns with the idea when it was being discussed in the abstract, warning the it segment the market between healthy people choosing the non-compliant plans and sick people the comprehensive ACA ones. The insurers upped their complaints in the letter Friday.

“This would allow the new plans to ‘cherry pick’ only healthy people from the existing market making coverage unaffordable for the millions of people who need or want comprehensive coverage, including, for example, coverage for prescription drugs and mental health services,” the insurers said.

The insurers also bashed the details of the proposal that became clear after it was unveiled, including an apparent attempt of have the non-compliant plans and the ACA plans share a single risk pool.

“That is not the case. The Consumer Freedom Option establishes a ‘single risk pool’ in name only. In fact, it creates two systems of insurance for healthy and sick people,” the insurers said.

They said that the $70 billion added to the new draft to offset premium increases for the sick “is insufficient and additional funding will not make the provision workable for consumers or taxpayers.”

They went on to predict that the proposal “will lead to far fewer, if any, coverage options for consumers who purchase their plan in the individual market.”

“As a result, millions of more individuals will become uninsured,” the letter said.

One more GOP defection from the legislation, which already has two Senate Republican opponents, would kill it even before the Senate could advance it procedurally, in a vote slated for this coming week.

Stated another way, the insurers basically said that the GOP description of the bill is nothing shirt of a huge lie.   Given the dishonesty of today's GOP, none of this should come as a surprise. 

Will Revived GOP Health Care Effort Bring Back Preexisting Condition Bars?

Those who have felt safer in the wake of the Republican Party's failure to pass legislation to repeal and "replace" Obamacare need to still be afraid.  Efforts are stirring among House Republicans to have another go at "reform" and the consequences could be that the health insurance market would return to much of its pre-Obamacare nature: those with preexisting conditions could be excluded from policy coverage and those with health problems could see premium costs soar to a point where any tax credits awarded under the GOP plan would barely scratch the costs of coverage.  To use a term the GOP coined, insurance companies would become death panels largely determining who gets treatment and who dies.  The main force behind the effort id the "conservative" House Freedom Caucus, a group that espouses respect for Christian values but which obviously has cast aside the Gospel message of caring for the sick.  A piece in the New York Times looks at the foul proposals brewing in the House of Representatives.  Here are excerpts: 

Monday night, word emerged that the White House and the group of conservative lawmakers known as the Freedom Caucus had discussed a proposal to revive the bill. But the proposed changes would effectively cast the Affordable Care Act’s pre-existing conditions provision aside.

The terms, described by Representative Mark Meadows, Republican of North Carolina and the head of the Freedom Caucus, are something like this: States would have the option to jettison two major parts of the Affordable Care Act’s insurance regulations. They could decide to opt out of provisions that require insurers to cover a standard, minimum package of benefits, known as the essential health benefits. And they could decide to do away with a rule that requires insurance companies to charge the same price to everyone who is the same age, a provision called community rating.

The proposal is not final, but Mr. Meadows told reporters after the meeting that his members would be interested in such a bill. To pass the House, any bill would need to find favor not just with the Freedom Caucus, but also with more moderate Republicans. It would also need to attract the support of nearly every Republican in the Senate to become law.

The ability to opt out of the benefit requirements could substantially reduce the value of insurance on the market. A patient with cancer might, for example, still be allowed to buy a plan, but it wouldn’t do her much good if that plan was not required to cover chemotherapy drugs.

The second opt-out would make the insurance options for those with pre-existing conditions even more meaningless.

Technically, the deal would still prevent insurers from denying coverage to people with a history of illness. But without community rating, health plans would be free to charge those patients as much as they wanted. If both of the Obamacare provisions went away, the hypothetical cancer patient might be able to buy only a plan, without chemotherapy coverage, that costs many times more than a similar plan costs a healthy customer. Only cancer patients with extraordinary financial resources and little interest in the fine print would sign up.

There is a reason that many conservatives want to do away with these provisions. Because they help people with substantial health care needs buy relatively affordable coverage, they drive up the price of insurance for people who are healthy. An insurance market that did not include cancer care — or even any cancer patients — would be one where premiums for the remaining customers were much lower. The result might be a market that is much more affordable for people with a clean bill of health. But it would become largely inaccessible to anyone who really needs help paying for medical care.

We do not have to speculate to know what the world looks like without essential health benefits and community rating. It was how most state insurance markets worked before Obamacare. Back in 2009, most sick people who did not get insurance through work or a government program were excluded from coverage if they had a history of health problems like allergies or arthritis. Plans that did not cover pregnancy care or drug addiction treatment were widespread.

[I]nsurance in the old high-risk pools tended to be expensive, and often came with long waiting periods or benefit limitations, even for the very sick.

What states would choose to do with this set of options is hard to predict. Before Obamacare, few states required community rating of health plans. And few states required insurers to cover all of the benefits deemed essential under Obamacare, though most did require a few types of treatments to be covered. State governments would face a difficult choice: either take away the requirements, and leave sick patients without insurance options, or keep them and see people unable to afford coverage under the new subsidy system.

Mr. Meadows said that the proposal presented to the Freedom Caucus would retain the pre-existing conditions policy. But that would be true in only the most literal sense. The mix of policies could allow insurance companies to charge sick people prices that few of them could pay. And it could allow them to exclude benefits that many healthy people need when they get sick. The result could be a world where people with pre-existing conditions would struggle to buy comprehensive health insurance — just like before Obamacare.

As I have argued for some time, the only real solution is a single payer system like the rest of the advanced world utilizes that would take the power of life and death away from insurance companies.  It is really that simple. 

Health Insurers Plan To Debunk GOP's 'Rigged' Obamacare Study

I just finished my May, 2014, column for VEER Magazine which looks at the issue of Medicaid expansion in Virginia.  Much of the column looks at the lies and disinformation that is now the norm in terms of GOP talking points and "studies."   Rather than met countervailing arguments with facts and objective evidence, the GOP has a new standard modus operandi: lie and/or cook study results just like Mark Regnerus in his infamous anti-gay parenting farce.  The truth simply doesn't matter in today's GOP.  As Talking Points Memo notes, a number of health insurance companies seem poised to expose the lie in a new GOP "study" that sought to discredit enrollments under the Affordable health Care Act.  Here are highlights:

Insurance companies plan to effectively debunk the House GOP's much-derided Obamacare survey at a Wednesday hearing.

The hearing is a follow-up to last week's report from the House Energy and Commerce Committee, and is hosted by one of its subcommittees, that found only 67 percent of Obamacare enrollees had paid their premiums as of April 15. An industry source described the survey to TPM as "incredibly rigged" because it excluded any premium payments that were due April 30 or later.

Roughly 3 million of Obamacare's 8 million enrollees would have had payments due after April 15 because they signed up March 15 or later.

A follow-up letter sent to insurers by the committee seemed to indicate that companies had raised that issue. Testimony prepared for Wednesday's hearing, and which was first reported by Bloomberg, is another direct contradiction of the Republicans' methodology.

Dennis Matheis, a vice president at WellPoint, one of the nation's largest insurers, plans to point out the payment percentage is much higher if you count only the payments that have actually come due, up to 90 percent:

The percentage of applicants that have paid a premium will differ depending on whether the percentage is calculated based on the total number of applications and premium payments received during this entire time period (roughly 70 percent) or is calculated based on the total number of applications and premium payments received for policies whose premium deadline has passed (ranging up to 90 percent depending on the state).

Paul Wingle, an executive at Aetna, plans to make the same point, estimating his company's customers are paying at better-than-80-percent clip:

For those who had reached their payment due date, the payment rate, though dynamic, has been in the low- to mid-80 percent range.

A third industry witness, J. Darren Rodgers of Health Care Services Corp., plans to stress that the last segment of payment data "is not yet complete given that deadlines for all of those policies may not yet have passed."

I once was proud to be a Republican.  Now I find myself embarrassed to have ever been involved in the GOP.  Truth, logic, honesty, reason,  have all gone out the window and I remain convinced that the decline of those values directly correlates to the rise of the Christofascists in the GOP base.  To be a GOP elected official requires that one be little more than a pathologically lying whore.

Obama Administration: Insurers Cannot Discriminate Against Gay Couples

In what is good news for many same sex couples, the Obama administration has issued a directive that insurers are prohibited from discriminating against same-sex marriages for the purposes of non-grandfathered family coverage.  The rule applies even in non-marriage equality states, such as Virginia.  Even with improvements under the Affordable Health Care Act, securing health insurance remains difficult for many and being able to go on one's partner/spouse's coverage is for many the most practical route.  Yet some insurance carriers have baulked at adding partner/spouse to family coverage.  The Washington Blade looks at this welcome development.  Here are highlights:

The Obama administration clarified on Friday that insurers are prohibited from discriminating against same-sex marriages for the purposes of non-grandfathered family coverage — even if applicants are applying in non-marriage equality states.

In guidance dated March 14, the Centers for Medicare & Medicaid says existing provisions in the health care reform law prohibiting discrimination by insurers on the basis of gender — which the Obama administration has interpreted to extend non-discrimination protections based on sexual orientation and gender identity — also requires insurers not to refuse family coverage for married same-sex couples.

Alicia Hartinger, a CMS spokesperson, said the guidance spells out that non-discrimination is the rule for insurers — both on and off the health insurance exchanges — when selling policies.

“CMS recognizes the importance of all Americans and their families having access to quality, affordable coverage,” Hartinger said. “Today’s guidance clarifies that issuers may not choose to treat same-sex spouses differently from opposite-sex spouses. If an issuer offers opposite-sex spouse coverage, it may not choose to deny the same coverage to a same-sex spouse. We will continue to work with states and issuers to help ensure all Americans have an equal opportunity to purchase the new coverage options available to them.”

The guidance says insurers cannot refuse family coverage to married same-sex couples even if they live in — or the insurance is sold in — a non-marriage equality state that doesn’t recognize those unions.

LGBT advocates praised the new guidance as a step toward ensuring that married same-sex couples have the same access to health insurance as their opposite-sex counterparts.

There have been reported incidents of married gay couples being unable to receive family coverage in the aftermath of the implementation of the Affordable Care Act. In February, a gay couple — Alfred Cowger and Anthony Wesley of Gates Mills, Ohio — filed a federal lawsuit charging that they were unable to obtain family coverage because their state doesn’t recognize their marriage.

In January, Blue Cross and Blue Shield canceled family insurance policies it sold to same-sex couples under the Affordable Care Act in North Carolina. Following news reports about the cancellations, the insurer changed course and agreed to offer family coverage on the health insurance exchange to same-sex couples.

Health Insurers Gave Millions to Fund Anti-Reform Ads

I cannot say that I'm surprised. America's health insurance industry is about as bad a pathological liar as are the Christianist when speaking about gays and homosexuality. Lies, deceit, and underhanded tactics are the norm and truth is entirely eliminated. Think Progress has a new story on the millions of dollars funnelled by health insurance companies to fund advertisements arguing against health care reform. Sadly, many blue dog Democrats are firmly in bed with the health insurers and drug manufacturers rather than average Americans and their families. Here are some highlights:

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Last September, ThinkProgress reported that, despite its public support for health care reform, the insurance industry was engaged in a “duplicitous” campaign to undermine the effort. Now the National Journal has confirmed that from September to December 2009, “six of the nation’s biggest health insurers began quietly pumping big money into third-party television ads aimed at killing or significantly modifying the major health reform bills moving through Congress.” The companies used America’s Health Insurance Plans — the lobbying arm of the insurance industry — “as a conduit to avoid a repeat of the political flack that hit the insurance industry after it famously ran its multi-million dollar ‘Harry and Louise’ ads to help kill health care reforms during the Clinton administration.
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That money, between $10 million and $20 million, came from Aetna, Cigna, Humana, Kaiser Foundation Health Plans, UnitedHealth Group and Wellpoint, according to two health care lobbyists familiar with the transactions. The companies are all members of the powerful trade group America’s Health Insurance Plans. The funds were solicited by AHIP and funneled to the U.S. Chamber of Commerce to help underwrite tens of millions of dollars of television ads by two business coalitions set up and subsidized by the chamber. Each insurer kicked in at least $1 million and some gave multi-million dollar donations.
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The industry’s covert ad campaign isn’t the industry’s only means of wasting millions of premium dollars on sabotaging reform. As former health insurance executive Wendell Potter told ThinkProgress, insurers are using a variety of front groups to advance a hidden attack campaign. The industry regularly feeds talking points to right-wing media like Rush Limbaugh and Fox News, mobilizes anti-reform “grassroots” groups and coordinates with conservative think-tanks to produce academic-appearing reports to advance their cause.
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The insurance industry has also funded state efforts to challenge the constitutionality of health reform. Insurers have “spent heavily on political contributions” in the 14 states seeking to ratify constitutional amendments that would repeal all or parts of the new measure and contributed thousands of dollars to the attorneys generals seeking to disqualify reform. Earlier this month, Lee Fang reported that Blue Cross Blue Shield Association “played a pivotal role in crafting this anti-health reform states’ rights initiative.”
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Based on his failure to support a viable public option, it looks as it President Obama also was a recipient of health care lobby funding. Between needless advertising and dishonest anti-reform ads, the health care insurers have squandered funds that should have been used to lower premium costs.

American Medical Association: Stop Discriminating Against Transgender Patients

Raw Story has a story about what one would think would be a common sense issue, namely providing appropriate medical treatment to transgendered individuals. Unfortunately, too many health insurance carriers are always seeking ways to deny coverage for procedures. Now the American Medical Association has stepped into the fray and taken a formal position that treatment should not be denied. While I cannot fully get my head around what it must be like to be transgendered, I guess straights have the same issue with gays. That doesn't mean that all of us should not recive appropriate medical care regardless of our sexual orientations or gender expression. Here are some highlights on the AMA's statements:

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The American Medical Association is calling on health insurers to cooperate with doctors in providing proper care to meet transgender patients' needs. Resolutions 114, 115 and 122 were passed by the AMA's House of Delegates at its annual conference in Chicago, which concludes today. Noting that Gender Identity Disorder is an internationally recognized medical condition, the Delegates highlight the need to combat the emotional pain and physical incongruity associated with gender dysphoria with proper access to mental health services, hormone treatments, and surgical procedures.

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The AMA asserts that when discriminatory financial barriers are placed between the transgender community and proper health care by dismissing treatments as "cosmetic" or "experimental," even when covered for other patients with other recognized medical conditions, more expensive problems can develop as a result, such as depression, substance abuse problems, and stress-related illness. The National Center for Transgender Equality has hailed the resolution.

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"Doctors and patients, not insurance companies, should be making those choices," Keisling [of NTCE] added. "We are so glad that the AMA has taken a leadership role against the rampant discrimination that transgender people have faced for so many years in receiving appropriate medical care and equitable insurance coverage."