Subpar Consumer Experiences with Health Insurance

Summary: Surprise, surprise – our fragmented, profit-driven, gap-permeated health insurance “system” leads to terrible consumer experiences accessing health care. It’s time, finally, to adopt a simple, efficient and generous solution – single payer.

Survey of Consumer Experiences with Health Insurance
June 15, 2023
By Karen Pollitz, et al.

Key Findings

*  Most insured adults give their health insurance positive ratings, though people in poorer health tend to give lower ratings. … 84% of people who describe their physical health status as at least “good” rate insurance positively, compared to 68% of people in “fair” or “poor” health.

*  Despite rating their insurance positively, most insured adults report experiencing problems using their health coverage; people in poorer health are more likely to report 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.

*  Nearly half of insured adults who had insurance problems were unable to satisfactorily resolve them, with some reporting serious consequences.

*  Among those with the greatest mental health needs, many adults across insurance types find their coverage lacking and report forgoing needed care. Among insured adults who report being in “fair” or “poor” mental health, four in ten (43%) say there was a time in the past year when they did not get mental health services or medication they thought they needed …

*  Affordability of premiums and out-of-pocket costs are a concern, particularly for those with private health coverage, and for some, contributed to not getting care.

*  Insured adults overwhelmingly support public policies to make insurance simpler to understand and to help them avoid or resolve insurance problems.

Adults with Medicare are the most positive in their overall ratings with nine in ten (91%) rating their coverage positively, including half who say it is “excellent.”

Marketplace enrollees, regardless of health status, are the most likely to rate their insurance negatively.

Over the years, Congress has enacted a number of measures to make health insurance more understandable and easier to navigate, and to hold health insurers and public programs accountable for the coverage they promise. Alone, these measures are unlikely to eliminate all the problems people encounter with health insurance, especially those related to affordability, but they may help to reduce somewhat the dizzying complexity of health insurance in the U.S. And they may inform oversight so that regulators can better monitor how well insurance works when people need to use it. At the same time, stronger oversight and accountability could entail more administrative costs – a trade-off we did not probe in this survey.

Comment by: Don McCanne & Jim Kahn

This comprehensive survey should be read in its entirety to understand the startling inadequacy of US health insurance under our complex combination of public and private plans and no insurance at all. Despite its failings, it is the most expensive health system of all nations.

One of the major deficiencies in our system is the very high administrative costs which waste funds that could be filling the voids in care, so it is ironic that Congress responds to the recognized problems with even more administrative burdens. Which “may help to reduce somewhat the dizzying complexity of health insurance in the US” … wow, how low can we set expectations?

Viewing the report, much of the problem lies with the tools used by the private insurance industry, but when you think about that, it is not too difficult to understand why. Private insurance is designed primarily to make generous profit for the owners – the billionaire shareholders whose goal is further wealth accumulation. On the other hand, truly public insurance is owned by the people of the nation and is designed specifically to deliver health care to those who need it.

When you read the findings, it’s obvious that all we would have to do to correct the deficiencies is to make the entire insurance program public. The simplest, most efficient, most effective, and most equitable way would be to enact and implement a single payer (an improved Medicare for All) that includes everyone, a single payer that we, the people, own. The problems listed in the Key Findings above would melt away.

But this does mean that elected leaders would have to put in place policies that serve the people rather than the private insurers and their investors. This last point we must tackle seriously now. Really! Access to health care is at stake, as the report vividly describes.


Moral Crisis for US Physicians

Summary: The corporate takeover of medicine has forced doctors to deviate from their healing mission to attend to financial optimization for their employers. This is indeed a moral crisis. Harkening back to the huge benefit that Medicare offered seniors 57 years ago reminds us of the universal medical access and health focus we would achieve with Medicare for All.

A Moral Crisis of America’s Doctors
The New York Times
June 15, 2023
By Eyal Press

The corporatization of health care has changed the practice of medicine, causing many physicians to feel alienated from their work.

In July, 2018, psychiatrist Wendy Dean published an article with Simon G. Talbot, a plastic and reconstructive surgeon, that argued that many physicians were suffering from a condition known as moral injury. Doctors on the front line of America’s profit-driven health care system were susceptible to such wounds 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.”

Throughout the medical system, the insistence on revenue and profits has accelerated. This can be seen in the shuttering of pediatric units at many hospitals and regional medical centers, in part because treating children is less lucrative than treating adults. It can be seen in emergency rooms that were understaffed because of budgetary constraints. And it can be seen in the push by multibillion-dollar companies like CVS and Walmart to buy or invest in primary-care practices, a rapidly consolidating field attractive to investors because many of the patients who seek such care are enrolled in the Medicare Advantage program, which pays out $400 billion to insurers annually. Over the past decade, meanwhile, private-equity investment in the health care industry has surged, a wave of acquisitions that has swept up physician practices, hospitals, outpatient clinics, home health agencies. The staffing in 30 percent of all emergency rooms is now overseen by private-equity-owned firms.

As the focus on revenue and the adoption of business metrics has grown more pervasive, young people embarking on careers in medicine are beginning to wonder if they are the beneficiaries of capitalism or just another exploited class. In 2021, the average medical student graduated with more than $200,000 in debt. In the past, one privilege conferred on physicians who made these sacrifices was the freedom to control their working conditions in independent practices. But today, 70 percent of doctors work as salaried employees of large hospital systems or corporate entities, taking orders from administrators and executives who do not always share their values or priorities.

Young doctors are noticing how the emphasis on the bottom line routinely puts them in moral binds, and they in particular are contemplating how to resist. “I think a lot of doctors are feeling like something is troubling them, something deep in their core that they committed themselves to,” Dean says. “Not only are clinicians feeling betrayed by their leadership, but when they allow these barriers to get in the way, they are a part of the betrayal. They’re the instruments of betrayal.”

Comment by: Don McCanne

Well, this is depressing. Read the full article if you’re in the mood to be in a funk. But does it really have to be this way? Do we have to put up with a health care financing system that is causing moral injury? I think that the clear answer is “no,” and I have proof.

My twin and I joined our father and brother in practice in 1966, a few months before Medicare was initiated. Just imagine what took place for our patients over 65. Suddenly essentially all financial barriers to care were removed for that patient population. We could get them all of the care that they needed. It didn’t take me long to figure out that we should expand Medicare to cover everyone, and I’ve been advocating for it ever since.

In the meantime, corporatization, such as with the Medicare Advantage plans and ACO REACH, has played havoc with the program, and CMS is continuing in that vein such as with the forthcoming 10 year “Making Primary Care” experimental program. But that does not mean that we cannot reverse these nefarious aberrations and reestablish Medicare as a traditional health care financing program like it was before, even better than other private and public insurance plans were before greed became the primary driving force.

Obviously we need reform. Absent politics, the easiest step to correct almost all of our deficiencies would be the enactment and implementation of a single payer financing system. It will be difficult to design the system to reduce the impact of corporatization so that the funds go to patient care rather than private investors. But it sure would be nice to have a health care financing system like it was for our senior patients in 1967. No longer would our young physicians feel like they are instruments of betrayal.


Learning from Other Countries

Summary: An excellent op-ed in the New York Times properly highlights lessons from other wealthy nations. Diving deeper into those examples reveals that single payer is the only plausible path to achieving efficient and equitable health care financing in the US.

I Studied Five Countries’ Health Care Systems. We Need to Get More Creative With Ours.
New York Times
June 14, 2023
By Aaron E. Carroll

[H]ealth care reform doesn’t seem to be a top political issue in the United States right now. That’s a mistake. The American health care system is broken. We are one of the few developed countries that does not have universal coverage. We spend an extraordinary amount on health care, far more than anyone else. And our broad outcomes are middling at best.

When we do pay attention to this issue, our debates are profoundly unproductive. Discussions of reform here in the United States seem to focus on two options: Either we maintain the status quo of what we consider a private system or we move toward a single-payer system like Canada’s. That’s always been an odd choice to me because true single-payer systems like that one are relatively rare in the world, and Canada performs almost as poorly as we do in many international rankings.

In the first half of the year, I was privileged to visit five other countries and learn about their health care systems. In February I traveled to Britain and France with Indiana University’s Kelley School of Business and, more recently, with the Commonwealth Fund and AcademyHealth to New Zealand, Australia and Singapore.…

America could learn a thing or two from these other countries. We could take inspiration from them and potentially improve access, quality and cost. However, it’s important to frame our examination correctly. Focusing on these countries’ differences misses the point. It’s what they have in common — and what we lack — that likely explains why they often achieve better outcomes than we do.

Universal coverage matters. What doesn’t is how you provide that coverage, whether it’s a fully socialized National Health Service, modified single-payer schemes, regulated nonprofit insurance or private health savings accounts. All of the countries I visited have some sort of mechanism that provides everyone coverage in an easily explained and uniform way. That allows them to focus on other, more important aspects of health care.

But the United States can’t decide on a universal coverage scheme, and not only does it leave too many people uninsured and underinsured; it also distracts us from doing anything else. We have all types of coverage schemes, from Veterans Affairs to Medicare, the Obamacare exchanges and employer-based health insurance, and when put together, they don’t work well. They are all too complicated and too inefficient, and they fail to achieve the goal of universal coverage. Our complexity, and the administrative inefficiency that comes with it, is holding us back.

When I was younger, I was more of a single-payer advocate, until I realized how many systems perform better than Canada’s. More recently, I favored the tightly regulated, entirely private insurance system of Switzerland because it performs exceptionally well using a private scheme I thought would be more palatable to many Americans. Today, though, I really don’t care how we get to universal coverage.

If we could agree on a simpler scheme — any one of them — we could start to focus on what matters: the delivery of health services. …

What separates the countries I traveled to from the United States is that they largely depend on public delivery systems. Most people get their hospital care from a government-run facility. However, each country also has a private system that serves as a release valve. If people don’t like the public system, they can choose to pay more, either directly or indirectly, through voluntary private health insurance, to get care in a different system. …

In fact, explicit tiering is a feature, not a bug, of all of these other systems. Those who want more can get more, even in Singapore’s public system. But more isn’t better care; it’s more choice in terms of physicians, private rooms, fancier food and even air conditioning. (While many Americans see the latter as a necessity, most people in Singapore — where it’s much hotter — don’t agree.)

In the United States, on the other hand, most care is provided by private hospitals, either for-profit or nonprofit. Even nonprofit systems compete for revenue, and they do so by providing more amenity-laden care. This competition for more patient volume leads to higher prices, and while we don’t explicitly ration care, we do so indirectly by requiring deductibles and co-pays, forcing many to avoid care because of cost. …

I’m convinced that the ability to get good, if not great, care in facilities that aren’t competing with one another is the main way that other countries obtain great outcomes for much less money. It also allows for more regulation and control to keep a lid on prices.

I’m not arguing it would be easy to expand the number of public hospitals in the United States. It would be politically difficult to expand the government’s role in delivering health care, directly or indirectly. But allowing people to choose whether to accept cheaper care delivered by a public system or to pay more for care in a private system might make this much more palatable. By doing so, we could make sure that good care is available to all, even if better care is available to some.

Comment by: Jim Kahn

Dr. Carroll offers many cogent observations: the failure of our health system, the paramount importance of universal coverage, the valuable role of public providers, and the wisdom of investing in non-medical social welfare programs. He appropriately highlights admirable examples of universal coverage in other wealthy countries. I even accept his observation that the Canadian single payer system isn’t the most popular among single payer approaches.

What he fails to do is note the critical features of successful national insurance systems. Here they are:

1) Universal coverage with an identical broad benefit package. That is, everyone has the same excellent coverage, and the same payment rates. This is a far cry from universal coverage as defined in the US. It is essential for both equity and efficiency.

2) This universal coverage is provided by the government or not-for-profit insurers. Even in Switzerland and the Netherlands, cited as examples for feasibility of a private insurance model, these insurers provide standard comprehensive benefits without taking profit. He alludes to the not-for-profit highly regulated use of insurers. But he fails to point out that this model has nothing to do with how US private insurers operate.

3) Additional private insurance, such as for access to more providers or to cover cost-sharing, is a very small portion of total health spending, typically just a few percent. It’s the exception, not the system; the frill, not the core.

4) Cost-sharing is low, maximum hundreds of dollars instead of thousands or tens of thousands in the US. That’s critical for access to care, with nearly half of adults delaying or skipping care for financial reasons.

5) Providers deal with only one payer, instead of dozens here. This allows them to focus on clinical care instead of payment activities, which currently consume about 15% of US health care costs.

6) Drug prices and provider payment rates are regulated and negotiated centrally. This assures reasonable prices, not the outlandish levels so often seen in the US. 

So … if the US is to learn from foreign experience, as it should, it’s not just about universal coverage. It’s about excellent identical insurance, with no profit motive, no or little cost-sharing for patients, simplicity for providers, and negotiated uniform prices. Our private insurers don’t and can’t align with these essential conditions. Ergo, single payer.


CMS Primary Care Fiddling Instead of Real Reform

Summary: CMS is proposing a 10-year comparison of primary care payment models (fee-for-service and capitation, with support for care delivery systems). At first glance, why not? On closer scrutiny, this is another delay for an experiment in our current flawed system that will yield limited and equivocal results. Let’s focus on real reform.

Making Care Primary (MCP) Model
Centers for Medicare & Medicaid Services
June 8, 2023

On June 8, 2023, the Centers for Medicare & Medicaid Services (CMS) announced a new voluntary primary care model – the Making Care Primary (MCP) Model – that will be tested in eight states. Launching July 1, 2024, the 10.5-year model will improve care management and care coordination, equip primary care clinicians with tools to form partnerships with health care specialists, and leverage community-based connections to address patients’ health needs as well as their health related social needs (HRSNs) such as housing and nutrition. CMS is working with State Medicaid Agencies in the eight states to engage in full care transformation across payers, with plans to engage private payers in the coming months.

To support team-based care, MCP will include prospective payments for primary care that will reduce organizations’ reliance on fee-for-service payments. Risk-adjusted enhanced services payments, which will also be paid prospectively and represent an additional investment in primary care, will allow participants to expand care management, screen for health-related social needs, and integrate with specialty care.

Track 1 – Building Infrastructure. Payment for primary care will remain fee-for-service (FFS), while CMS provides additional financial support to help participants develop care transformation infrastructure and build advanced care delivery capabilities. Participants can begin earning financial rewards for improving patient health outcomes in this track.

Track 2 – Implementing Advanced Primary Care. Payment for primary care will shift to a 50/50 blend of prospective, population-based payments and FFS payments. CMS will continue to provide additional financial support at a lower level than Track 1, as participants continue to build advanced care delivery capabilities. Participants will be able to earn increased financial rewards for improving patient health outcomes.

Track 3 – Payment for primary care will shift to fully prospective, population-based payment while CMS will continue to provide additional financial support, at a lower level than Track 2, to sustain care delivery activities while participants have the opportunity to earn greater financial rewards for improving patient health outcomes.

To be eligible to participate in MCP, an organization must be a legal entity formed under applicable state, federal, or Tribal law authorized to conduct business in each state in which it operates.

Comment by: Don McCanne & Jim Kahn

At first glance, this may seem like a decent idea: explore different payment models for primary care within Medicaid and, if they agree, private insurers. Compare results over an extended period of time, between supplemented FFS, FFS-capitation, and fully capitated approaches.

But, then, it hits us: Here we go again! Ten more years of fiddling with a broken system, while avoiding real financing reform.

Of course, we need to ask, based on recent trends in Medicare and more broadly … who is going to own these “legal entities”? Private equity? The billionaires?

The hazards of capitation are clear: Increase the monthly payment level for providers who have better health outcomes, that is, healthy patients who may not need much care. And link these payments to diagnostic (up)coding via risk adjustment. The truly sickest and costliest patients can go elsewhere, to providers paid fee-for-service. Avoiding the chronically ill might not be the goal of the traditional health care providers with their Hippocratic traditions, but, under this CMS model, certainly it would be a primary goal of their entrepreneurial employers and their billionaire investors. That’s what we’ve seen in Medicare Advantage and in CMS ACOs.

If past experience informs, the benefits of new strategies will be modest and mixed, hard to interpret but with each slight drop in cost or isolated gain in outcomes lauded by CMS as major successes. Corporations will manipulate the evaluation findings to serve business purposes.

The unclear role of private payers is telling. What we need is primary care for all, not clunky semi-coordination of different payers in a hard-to-interpret demonstration project.

Real reform can’t be off the agenda for the next decade, while we wait for this and other tweaks to our broken system. This CMS proposal requires a response from us. We already have a great start: Medicare for All legislation in both the Senate and the House (Thank you Sanders, Jayapal, Dingell, and the many others). We need to go to the streets, not with guns, but with our placards and loud, passionate voices! And this time, let’s not just go home when the shouting is done. Let’s complete the job!


Efficiency Gone Astray in Health Care

Summary: Our medical system defines efficiency as maximizing revenue-generating care. This compromises clinical interactions and indeed access to care, as highlighted in today’s excerpts. Single payer defines efficiency as eliminating wasteful non-clinical tasks and paying fair prices … to achieve universal access to high quality care.

Twitter post (video 2 min)
Dr. Mark Lewis
May 28, 2023

This son of a preacher man worries that he’s losing both the spirit of medicine and the identity of the patient when we reduce clinical encounters to measurable (and, not coincidentally, billable) “value units”

This Nonprofit Health System Cuts Off Patients with Medical Debt
New York Times
June 1, 2023
By Sarah Kliff & Jessica Silver-Greenberg

Doctors at the Allina Health System, a wealthy nonprofit in the Midwest, aren’t allowed to see poor patients or children with too many unpaid medical bills.

Many hospitals in the United States use aggressive tactics to collect medical debt. They flood local courts with collections lawsuits. They garnish patients’ wages. They seize their tax refunds.

But a wealthy nonprofit health system in the Midwest is among those taking things a step further: withholding care from patients who have unpaid medical bills.

Allina Health System, which runs more than 100 hospitals and clinics in Minnesota and Wisconsin and brings in $4 billion a year in revenue, sometimes rejects patients who are deep in debt, according to internal documents and interviews with doctors, nurses and patients.

Although Allina’s hospitals will treat anyone in emergency rooms, other services can be cut off for indebted patients, including children and those with chronic illnesses like diabetes and depression. Patients aren’t allowed back until they pay off their debt entirely.

About 20 percent of hospitals nationwide have debt-collection policies that allow them to cancel care, according to an investigation last year by KFF Health News. Many of those are nonprofits. The government does not track how often hospitals withhold care.

Comment by: Jim Kahn

Efficiency is good. That view is integral to my identity as a health economist. By efficiency, I mean the ability to achieved agreed-upon goals with the fewest possible resources, via minimized waste. Put differently: to maximize reaching our goals with the resources we have. In health care, to raise access to care and reduce disease.

Yet in today’s health care system efficiency is used in the service of revenue and profit. Provider organizations are adept at using “relative value units” (the payment unit for outpatient care) and aggressive billing practices to maximize revenue. Even not-for-profits adopt these industry norms and practices. The result is reduced time with patients and, as we see with Allina, denial of care access. This harm affects physicians too: burnout from intense work conditions and the moral hazard of providing suboptimal care.

My colleague, retired gastroenterologist and long-time single payer advocate John Roark, puts it very well: “Business profits have commandeered something that’s laudable. Corporations, rhetoric aside, aren’t really interested in other things. It’s much more likely that with single payer the health care system would make a more honest attempt to treat human beings as human beings.”

Right on, John. Treat human beings as human beings, not revenue centers to be pursued and cost centers to be shunned.