Health (No) Care

A Surviving Facts Blog

The media has written a lot about the shooting of the United Healthcare CEO Brian Thompson- so I’m sure by now you’ve heard about it. Of course, many have expressed dismay about the violence and have shared thoughts and prayers with his family, colleagues and friends. The loss of a father and husband is a tragedy. But even more, Americans have been using this as an opportunity to complain about the state of health insurance in our country.

United denies more claims than any other health insurance company- a whopping 32%! The industry average is 16%. United doubled that average by using AI to review and judge claims. According to many articles, the bot made frequent errors and often interpreted claims incorrectly. Also important to note- United made $281 billion last year. How? By denying claims and employing AI to speed through claim analysis.

Our healthcare system in the US is broken. We are the only first-world country that does not provide universal health coverage. While most developed countries see healthcare as a basic human right, in the US, we treat it as a privilege. Twenty-six million Americans are without health coverage. That equals 8% of the population. Surveys have shown that most of these people are low income workers (I.e., they have jobs) and people of color. This lack of coverage burdens the entire healthcare system. Without insurance, these Americans are forced to use emergency rooms to resolve even minor illnesses, costing the US billions annually. Since the ACA was implemented, uncompensated care for the uninsured has cost around $43 billion each year (a decrease, actually. It was previously 60+B), and this number is not a current statistic (KFF).

Even those with health insurance are struggling with cost and coverage. According to KFF, half of US adults struggle to pay for their health insurance and prescription drugs. In fact, in 2021, $88 million in health care debt was reported to collection agencies. In addition, insured Americans report skipping prescriptions because they cannot pay for them.

So what’s the solution? Americans are sick and tired of being sick and tired. The constant battling through health insurance delays and denials is demoralizing. We are not getting healthier under our current system; we are getting sicker, physically and mentally. Americans are so frustrated that many lack empathy for the slain CEO. This indicates their experience with health insurance. This apathy comes from a growing disconnect between huge health insurance corporations and humans. The profit of health insurance companies conflicts with the needs of Americans.

So, I’m stepping into the fray with a few ideas.

1. Break the connection between companies and health care access. Health care should be available to everyone. It’s a human right. Relying on companies to provide access is unfair to individuals and companies. It’s an enormous cost for companies, conflicting with company goals, forcing more cost to be pushed to employees. In addition, many workers cannot get health insurance through their workplace, particularly if they work in the service industry or part time. All Americans should have access to health insurance and not need to work in a corporation to get it.
2. Where will Americans get health coverage? We have options. One is direct pay according to earnings and needs. Obviously, the wealthy should pay more for insurance than the poor. With this approach, low income workers can be subsidized within the system. There are other ways to fund- corporations could pay into a general fund. But the corporations should not select or facilitate employees’ insurance companies. The other option is socialized medicine, which leads to #3.
3. Does this mean government health insurance? Given the current political conflict between private and socialized medicine ideologies, I advocate for regulated health insurance rather than socialized. Insurance companies should be non-profit. Period. Americans’ health should not conflict with profit motive. Medicaid and Medicare, in my opinion, should be part of this system as well. One reason I advocate for this approach is my personal experience. I currently access health insurance through the market. The government-run approach is unbelievably inept. Constant mistakes plague the people who use it, including me. The folks on customer service are very nice, but they are stymied by resolving problems. I receive printed documents with the same information practically every week. Saving on paper alone would make a difference.
4. Health insurance needs an oversight board much like the Public Company Accounting Oversight Board. If health insurance were to remain independent in non-profit form, they still need to meet principles and act with humanity, ethics and kindness. While a Board of this type isn’t perfect, it does create accountability and oversight.
5. Health insurance companies should not make medical decisions. In November, Anthem made a unilateral decision to limit the time of coverage for anesthesia. How absurd. Anthem thinks a surgery should last 4 hours and will only pay for 4 hours. What if the surgeon runs into a problem, and the surgery lasts 6 hours? Interestingly, Anthem retracted this ruling after the shooting of United’s CEO.
6. Health insurance companies should not default to delay and deny. Without the profit motive, the goal of health insurance would be to cover needed treatments. The doctor is the decision maker on treatments, not the insurance company. Personally, I don’t think health insurance companies should have the right to deny claims. Doing so hurts the doctor-patient relationship and ultimately results in patients not getting the care they need or skipping care because they can’t afford it. I know what you’re thinking… how do we keep costs in check?
7. I believe there should be caps on prescription drug and medical costs. But let’s be reasonable. A doctor should not perform surgery for ridiculously low amounts. Get doctors involved in determining them. Caps should be reviewed annually for inflation. Fewer people are becoming physicians- almost 5% each year. The primary reasons are administrative tasks, poor work-life balance and insufficient salary. By 2036, the US is projected to have a shortage of doctors. We will need approximately 86,000 more doctors to meet the demand. Doctors are fleeing the system because they too are frustrated by health insurance companies questioning their care and limiting what they can do.
8. Mental health should be covered. This is an enormous problem. Americans’ mental health is declining, and insurance denials are climbing. Lack of coverage maintains the mental health stigma. Mental health is health care. The poor mental health coverage also fails to recognize the relationship between mental and physical health. Our brain is attached to our body. We need to look at the whole. We need a healthier America.
9. The focus should be on wellness. Insurance companies and doctors should not be making money off sicker and sicker Americans. Obesity is an enormous problem in our country, and yet, few insurance companies cover the new medicines that help Americans with this problem. These medicines may make surgeries for obesity obsolete. That equals less burden on health care. These medicines also have another advantage: dementia and insulin resistance are closely tied (in fact, many European countries call dementia type 3 diabetes). These drugs keep insulin resistance in check. In other words, these drugs reduce other costs. It’s short-term versus long-term thinking. Meanwhile, Americans get sicker.
10. Health insurance costs should be capped as well. Do you know how much individual private insurance costs? Outrageous costs- the insurance company has to make money after all. As noted above, I do get my insurance from the market. The correlation between earnings and premium is confusing at best. Once a government employee made a mistake on my application. I got charged an enormous premium that I’m still working to resolve- and I’ve been working on it for months. This is why I advocate for a semi- private, regulated system that puts decision-making with doctors and not bots or customer care individuals.
11. In network and out of network is ridiculous. Physicians should be covered by all insurance companies. Because of my health insurance shift, I’ve had to change doctors I’ve seen for 25 years. How does losing this care history make me healthier? It doesn’t. And currently, insurance companies don’t care if I’m healthier or not. I should be able to choose my own doctor. I know why insurance companies implemented these networks- to manage costs. It hasn’t worked. It’s pushed more and more cost to the consumer.
12. With only non-profit healthcare overseen by regulatory bodies, our healthcare should have manageable cost. No one should go bankrupt because they have cancer. This is why I recommend a regulated and managed direct pay system based on means. Even in countries with socialized medicine, individuals pay a managed amount.
13. The rich and the poor should have access to the same benefits. It’s ridiculous to have less access to care because you’re poor. I know lots of Americans only want to pay for their own portion. They don’t realize they already are subsidizing other government programs, and other people could be subsidizing them. We need to cultivate an “all boats rise together” mentality. When we all win, our country is better for it. Certainly our current system isn’t working, and it prevents all Americans from having health care access. What kind of people are we in this country not to provide healthcare for sick people? It’s practically barbaric to deny care. What if this were your child, mother, sibling, friend? Under the constitution, aren’t we all equal? (We should be, though we have lots of problems in this area too.)
14. No distinction between “rich and poor” plans should exist. Did you know that market plans that can be subsidized (this is the ACA), names these plans so that healthcare providers know they are subsidized? Each insurance company does it differently, but they all follow this system. What good does this serve? Does it encourage bias? I have suspected so. I’ve had doctor’s offices comment, “oh, this is from the market!” Why does it matter? My daughter was actually refused treatment once because of it. We were too tired to fight it.
15. The cost of prescription drugs has soared. While the ACA capped certain medications such as insulin, the new administration is threatening to repeal such caps. This means more Americans will be unable to afford much-needed medicines. Again, the profit motive should not interfere with a person’s health. This concept alone is mind boggling. A person’s wealth determines their health? Why? Because we have tied health care to profit-motive. As non-profits, healthcare companies need to be well run. They would be businesses still. The difference is the margins of revenue and the principles by which they operate.

Would any of these suggestions work? Some could. But we are not having this conversation in our country. In addition, the new administration and Project 2025 promise to cut healthcare rather than resolve it. The ACA-also known as Obamacare- reduced uncompensated health care costs by more than $20 billion dollars. Healthcare keeps people working and participating in society. No good comes from millions of sick Americans. No good comes from billions of dollars of unpaid medical care. No perfect solutions exist, but we have to start somewhere. For the good of our country and its citizens, we have to do better.

What do you think?

I would love to hear from you, even if, especially if, you disagree. Perhaps we can bring back the American tradition of civilized debate. Please like and share this blog with others. Subscribe to receive it by email and go directly to the Walk the Moon website to peruse the full collection of articles and updates.