PNHP

Medical resident Joey Ballard is fighting the good fight

Medical resident Joey Ballard is fighting the good fight

An Arm and a Leg Podcast, KFF, Dec. 30, 2024

A few weeks ago, a listener sent us a note with a link to a news article about a new resolution that had recently been adopted by the American Medical Association – the largest group representing doctors in the US.

The resolution said: hospitals need to do more to guarantee charity care to patients who qualify. Legislators and regulators should make them.

Our listener was the author of that resolution, and he told us he first learned about charity care through our work on this podcast.

His name is Joey Ballard and he’s an internal medicine resident at the University of Illinois-Chicago (UIC).

We talked with him about his early organizing as a medical student, bringing the resolution to the AMA, and the optimism he feels bringing the fight for charity care to the hospital he works at now.

Here’s a transcript of this episode.

Send your stories and questions. Or call 724 ARM-N-LEG.

https://armandalegshow.com…

Estimated US Deaths Associated with Health Insurance / Access to Care

The US has far higher mortality than other wealthy nations. Yet the fraction associated with health insurance issues and impaired access to care is difficult to estimate, due to elevated disease risk factors. This analysis estimates 200,000 annual deaths after adjustment for high-burden US diseases, potentially representing insurance-related mortality.

This week, a careful reader asked me to justify this estimate from November 2021: “The US excess mortality age 20-64 is about 1.4 per 1000 per year. Some of that is due to non-insurance factors. If 1.0 per 1000 is attributable to insurance, applied to the 190 million in this age range, that’s 190,000 extra deaths per year.”

In 2021, I was making a rough estimate by assigning most of the inter-country difference among adults 20-64 to health insurance. Perhaps I didn’t sufficiently emphasize the uncertainty of that estimate. Today, to “triangulate,” I took a different approach. I looked up death rates for major risk factors and diagnoses more common in the US than in other wealthy nations. This is not yet sufficiently refined for academic publication, but it’s a solid first cut, so I’m sharing it with HJM readers.

This finding of 195,032 annual deaths not explained by risk factors and diseases more common in the US is close to my prior estimate of 190,000. As noted, several of the totals may actually have medical insurance as a contributing cause – e.g., medical debt forcing people into poverty, or suicides associated with insurance worries or lack of access to mental health care. Thus, the 195,032 is likely a low estimate of insurance-related deaths.

To me, this high mortality burden is consistent with our fragmented and flawed insurance system, with half of adults experiencing financial barriers to care in any given year, often with reported health consequences. Growing rates of care denials are likely increasing the human toll, based on both reports of personal experiences and national surveys of physicians.

These kinds of estimates are imprecise, and indeed the uncertainty bounds are hard to specify. However, they are meaningful despite uncertainty. Whether the excess deaths due to insurance gaps total 195,000 per year, or 220,000, or 170,000, that’s hundreds of thousands too many deaths. The 45,000 estimated in 2009 for those lacking insurance altogether (ignoring under-insurance) is also too much, inexcusable.

We need universal public insurance providing broad benefits to everyone, to save lives and money.

https://healthjusticemonitor.org…

Sources:

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Health care in U.S. must be better

By Richard Bruning
The Baltimore Sun, Letters, Dec. 27, 2024

People are justifiably angry at the health insurance industry and the recent article highlighting their practices (“Luigi Mangione murder case draws scrutiny of health claim denial rates, with three of Maryland’s top insurers higher than average,” Dec. 17) validates those concerns. However, focusing on the failures of UnitedHealthcare and others distracts us from the overarching problem: our profit-driven health care system is broken.

The United States is the only developed country that does not guarantee health care to its populace. In 2022, 27.6 million were uninsured (8.4% of the population) and many more millions were underinsured. The United States spends 40% more than any other country in the world yet ranks 42 in health care outcomes.

In an op-ed piece in the New York Times, Andrew Witty ($25.2 million in salary/benefits), the CEO of UnitedHealth Group said he was “willing to partner with anyone … to find ways to deliver high-quality care and lower costs.” He should consult with Physicians for a National Health Program (PNHP) and Healthcare-NOW. For years, they have supported Improved Medicare for All. This program would guarantee every American continuous coverage from birth to death for all medically necessary services, regardless of income, employment status, pre-existing conditions or where they live. Because everyone would be in the same plan, administrative costs would plummet creating massive savings. PHNP estimates that 95% of all households would save money under this plan.

There is a solution to our healthcare morass but only if we have the courage to fight for the change we need.

https://baltimoresun.com…

Insurance CEO Murder Exposes Deep Anger at US For-Profit Healthcare

Interview with Dr. Phil Brewer

Politics, Policy, and Planet Podcast, WPKN, Dec. 19, 2024

PNHP-CT chair Dr. Phil Brewer discusses his views on the recent wave of public anger and frustration regarding our nation’s failing health insurance industry set off by the murder of UnitedHealthcare CEO Brian Thompson, as well as Physicians for a National Health Program’s ongoing campaign for the implementation of a universal, single-payer health care system in the U.S.

Dr. Brewer characterizes the American system of financing—and denying—health care as “not fair, not right, and definitely not the best health care.”

https://btlonline.org…

Readers Write: Government efficiency

MedPAC’s estimate that Medicare Advantage insurers are overpaid by 22%, while shocking, is way too low.

By Kip Sullivan
The Minnesota Star Tribune, Letters, Dec. 18, 2024

I really appreciated Jill Burcum’s column on the jaw-dropping overpayments to so-called Medicare Advantage plans (“Will Musk have the guts to take on insurers?” Strib Voices, Dec. 15). Donald Trump’s unofficial budget cutters, Elon Musk and Vivek Ramaswamy, should immediately focus on eliminating those mammoth overpayments. Burcum reported that the Medicare Payment Advisory Commission (MedPAC) estimated that Medicare Advantage insurers are overpaid by 22%, far more than they need to cover their 15% overhead and make a buck without delaying and denying health care, which they do with gusto.

Sad to say, MedPAC’s estimate, as shocking as it is, is way too low. MedPAC took into account only two factors that create overpayments — favorable selection and upcoding. MedPAC estimated favorable selection (enrolling healthier-than-average beneficiaries) raised payments by 9%, and upcoding (adding false or inappropriate diagnoses to patient medical records to make them look sicker) added another 13% (for a total of 22%). Four other factors — favorable deselection (sicker people leaving Medicare Advantage and returning to the original Medicare program), bonuses for scores on a worthless “quality measure,” pointless bonuses for selling insurance in rural counties, and an “induced utilization” subsidy that is too complicated to explain here — raise the overpayments to about 40%. Forty percent overpayment translates into about $150 billion in excess payments in 2024. To put that sum in context, consider that the Congressional Budget Office estimates that adding dental, hearing and vision coverage to traditional Medicare would cost roughly $80 billion annually.

Kip Sullivan is a member of the Health Care for All Minnesota policy committee.

https://startribune.com…

I Was a Health Insurance Executive. What I Saw Made Me Quit.

By Wendell Potter
The New York Times, Dec. 18, 2024

I left my job as a health insurance executive at Cigna after a crisis of conscience. It began in 2005, during a meeting convened by the chief executive to brief department heads on the company’s latest strategy: “consumerism.”

Marketing consultants created the term to persuade employers and policymakers to shift hundreds, and in many cases thousands, of dollars in health-care costs onto consumers before insurance coverage kicks in. At the time, most Americans had relatively modest cost-sharing obligations — a $300 deductible, a $10 co-payment. “Consumerism” proponents contended that if patients had more “skin in the game” they would be more prudent consumers of health care, and providers would lower their prices.

Leading the presentation was a newly hired executive. Onstage, he was bombarded with questions about how plans with high deductibles could help the millions of Americans with chronic conditions and other serious illnesses. It was abundantly clear that insurance companies would pay far fewer claims but many enrollees’ health care costs would skyrocket. After about 30 minutes of nonstop questions, I realized I’d have to drink the Kool-Aid and embrace this approach.

And I did, for a while. As head of corporate communications at Cigna from 1999 until 2008, I was responsible for developing a public relations and lobbying campaign to persuade reporters and politicians that consumerism would be the long-awaited solution to ever-rising insurance premiums. But through my own research and common sense, I knew plans requiring significant cost sharing would be great for the well-heeled and healthy — and insurers’ shareholders — but potentially disastrous for others. And they have been. Of the estimated 100 million Americans with medical debt, the great majority have health insurance. Their plans are simply inadequate for their medical needs, despite the continuing rise in premiums year after year.

I grew uneasy after the company retreat. But it took an impromptu visit to a free medical clinic, held near where I grew up in the mountains of East Tennessee, to come face to face with the true consequences of our consumerism strategy.

At a county fairground in Wise, Va., I witnessed people standing in lines that stretched out of view, waiting to see physicians who were stationed in animal stalls. The event’s organizers, from a nonprofit called Remote Area Medical, told me that of the thousands of people who came to this three-day clinic every year, some had health insurance but did not have enough money in the bank to cover their out-of-pocket obligations.

That shook me to my core. I was forced to come to terms with the fact that I was playing a leading role in a system that made desperate people wait months or longer to get care in animal stalls, or go deep into medical debt.

The tragic assassination of the UnitedHealthcare chief executive Brian Thompson has reinvigorated a conversation that my former colleagues have long worked to suppress about an industry that puts profits above patients. Over 20 years working in health insurance, I saw the unrelenting pressure investors put on insurers to spend less paying out claims. The average amount insurers spent on medical care dropped from 95 cents per premium dollar in 1993, the year I joined Cigna, to approximately 85 cents per dollar in 2011, after the Affordable Care Act restricted how much insurers can profit from premiums. Since then, big insurers have bought physician practices, clinics and pharmacy middlemen, largely to increase their bottom line.

Meanwhile, the barriers to medical care have gotten higher and higher. Families can be on the hook for up to $18,900 before their coverage kicks in. Insurers require prior authorization more aggressively than when I was an industry spokesman, which forces patients and their doctors through a maze of approvals before getting a procedure, sometimes denying them necessary treatment. Sure, the insurance industry isn’t to blame for all the problems with our health system, but it shoulders much of them. (In response to a request for comment, Cigna told The Times that Mr. Potter’s views don’t reflect the company’s and that Cigna is constantly working to improve its support for patients.)

At Cigna, my P.R. team and I handled dozens of calls from reporters wanting to know why the company refused to pay for a patient’s care. We kept many of those stories out of the press, often by telling reporters that federal privacy laws prohibited us from even acknowledging the patient in question and adding that insurers do not pay for experimental or medically unnecessary care, implying that the treatment wasn’t warranted.

One story that we couldn’t keep out of the press, and that contributed most to my decision to walk away from my career in 2008, involved Nataline Sarkisyan, a 17-year-old leukemia patient in California whose scheduled liver transplant was postponed at the last minute when Cigna told her surgeons it wouldn’t pay. Cigna’s medical director, located 2,500 miles away from Nataline, said she was too sick for the procedure. Nataline’s family stirred up so much media attention that Cigna relented, but it was too late. Nataline died a few hours after Cigna’s change of heart.

Nataline’s death affected me personally and deeply. As a father, I couldn’t imagine the depth of despair her parents were facing. I turned in my notice a few weeks later. I could not in good conscience continue being a spokesman for an industry that was making it increasingly difficult for Americans to get often lifesaving care.

One of my last acts before resigning was helping to plan a meeting for investors and Wall Street financial analysts — similar to the one that UnitedHealthcare canceled after Mr. Thompson’s horrific killing. These “annual investor days,” like the consumerism idea I helped spread, reveal an uncomfortable truth about our health insurance system: that shareholders, not patient outcomes, tend to drive decisions at for-profit health insurance companies.

Wendell Potter, a former vice president for corporate communications at Cigna, is president of the Center for Health and Democracy and writes the newsletter “Health Care un-Covered.”

https://nytimes.com…

CEO murder exposes growing anger with the corporate health system

Interview with Dr. Henry Abrons

KALW Public Media, Your Call, Dec. 17, 2024

On this edition of Your Call, we’re discussing the U.S. health insurance industry.

The recent killing of UnitedHealth Group CEO Brian Thompson has revealed the growing anger about the broken health care system. Since the passage of the Affordable Care Act, the country’s largest health insurers have raked in more than $371 billion in profits, according to The Lever’s Helen Santoro. She writes that more than 40 percent of that net income went to UnitedHealth Group, whose annual profits have skyrocketed by nearly 400 percent as the company now reportedly denies nearly one in three medical claims from its policyholders.

According to a Gallup survey, 62 percent of Americans say the federal government should ensure all Americans have health coverage.

Maureen Tkacik is investigations editor at the American Economic Liberties Project.

Dr. Henry Abrons is a physician, past-president of the California chapter of Physicians for a National Health Program, and advisory board member of Physicians for a National Health Program.

full audio: https://kalw.org…

The tricks and traps of Medicare ‘Disadvantage’ plans

By Brenda Gazzar
Code Wack Podcast, Dec. 16, 2024

Why are seniors between a rock and a hard place when choosing between various Medicare options? How do private Medicare plans, known as Medicare Advantage, limit patients’ options and why are they considered riskier than traditional Medicare? And what’s the ‘Medigap Trap?’

To find out, we spoke to Dr. Diljeet Singh, an integrative gynecologic oncologist and the incoming president of Physicians for a National Health Program [PNHP]. With more than 25,000 members across the United States, PNHP advocates for a universal, comprehensive, single-payer national health program.

Check out the Transcript and Show Notes for more!

https://heal-ca.org…

Ways to Fix the Health Insurance Debacle

By Diane Archer
The New York Times, Letters, Dec. 16, 2024

Re: “UnitedHealth Group C.E.O.: The Health Care System Is Flawed. Let’s Fix It,” by Andrew Witty (Opinion guest essay, nytimes.com, Dec. 13):

A recent Gallup poll shows Americans’ satisfaction with health care access, costs and coverage at an all-time low since polling began in 2000. Not surprising. Corporate health insurers have had free rein over our health care system, and it continues to deteriorate.

Yes, as Mr. Witty says, the killing of Brian Thompson, UnitedHealthcare’s chief executive, was unconscionable. So are the needless deaths of tens of thousands of Americans, the increased morbidity of millions more and the medical debt that 41 percent of Americans face.

UnitedHealth “succeeds” by impeding health care access, denying coverage and driving up costs. Mr. Witty knows that all too well. That’s how UnitedHealth maximizes profits.

If Mr. Witty really supports a health care system that works better for everyone, he should advocate Medicare for all — guaranteed affordable coverage — instead of blocking efforts for a government-administered system.

The writer is the president of Just Care USA and the founder and former president of the Medicare Rights Center.

https://nytimes.com…

Overhaul health care

By Patty Harvey and Corinne Frugoni, M.D.
San Francisco Chronicle, Letters, Dec. 16, 2024

California’s Office of Healthcare Affordability proposes to reduce health care costs by setting a 3% cap on cost growth, which, if violated by health plans and providers, will result in fines.

Such attempts at cost control only stick fingers in the dike of high costs and rampant hospital consolidation.

Fines to multibillion-dollar for-profit private companies are wrist slaps; attempts to control their profiteering cannot address finely honed, loophole acrobatics. Fines to physician practices will disrupt patient-clinician relationships.

By imposing fines, the state tacitly accepts middlemen who provide no medical care but do add to administrative complexity and waste.

Hayward’s St. Rose Hospital was saved from closure by herculean local efforts. Not all are so fortunate. According to the National Rural Health Association, 683 other rural hospitals are at risk of bankruptcy.

The misguided strategy of the state will not halt further closures.

A better solution, practiced by other industrialized democracies, is a universal, single-payer health care system, or Medicare for all, that protects hospital solvency and saves billions yearly.

Patty Harvey and Dr. Corinne Frugoni, co-chairs, Humboldt County chapters of Health Care for All-California and Physicians for a National Health Program.

https://sfchronicle.com…

Yes, condemn CEO’s murder, but know why people feel rage toward health insurers

Maybe all the people who have been harmed by the health insurance industry should join their voices with the voices of a coalition of activists for fairness and justice.

By Carol Paris, M.D.
The Tennessean, Dec. 16, 2024

In the aftermath of the recent murder of UnitedHealthcare CEO Brian Thompson, I feel both sympathy for his family’s loss and rage at the misrepresentation of the thousands of stories of needless anxiety, suffering and premature death that have flooded social media.

Whether the story posted is from a patient or a doctor, the antagonist is always the same – the health insurance industry.

In their anger, have some people overstepped the bounds of moral decency? Yes.

That’s something people do when they are chronically anxious about going into medical debt, and always vulnerable to the whims of a health insurance industry that profits from denying them care. But to make that the story is despicable.

People expressing anger at health insurers are different from Jan. 6 rioters

And that is just what the Washington Post editorial board did on December 7, “A sickness in the wake of a health insurance CEO’s slaying.”

These editors compared heart-wrenching posts on social media to the violent mob that stormed the Capitol on Jan. 6, 2021.

They categorized these posts as “very different in their degrees of moral transgression and practical impact, but similar in their embrace of extreme measures to right perceived wrongs.”

Apparently, these writers consider posting on social media one’s anger and frustration at UnitedHealthcare’s tactics of delaying and denying care in the service of record-breaking profit as “extreme measures to right perceived wrongs” but then dismiss them as of little “practical impact.”

Sadly, that’s my point. As much as I want to believe that this time our elected officials will listen to our deafening outcry and take substantive action on our behalf to, at the very least, sanction and regulate the health insurance industry, I’m not holding my breath.

Rather, I fear that this outpouring of rage at the health insurance industry will have no practical impact no matter how loudly or persistently we cry  because members of Congress are not listening to us. They listen to the threat of losing campaign contributions if they fail to do as their corporate donors demand.

Reformers and activists should unite to change the system

The Washington Post editors listen to their billionaire owner who proffers a narrative dictated by the health insurance industry “Wizards of Oz,” from behind the safety of the black curtain. Ignore all those silly Munchkins. The mighty Oz has spoken.

And once again, the moment is lost because wizards like Andrew Witty, CEO of UnitedHealth Group and Jeff Bezos, founder of Amazon and owner of the Washington Post, control the narrative to their financial advantage.

I wonder what would happen if all of us Munchkins came together and took control of the narrative?

Maybe all the people who have been harmed by the health insurance industry would join their voices with the voices of health reform activists, campaign finance reform activists, climate activists, reproductive justice activists, racial justice activists, fair wage activists, affordable housing activists, food security activists and more.

Just think of the power of all our voices, together, demanding a multitude of social justice reforms.

There are no unsolvable problems, but I find that the best solutions emerge by listening to a broad spectrum of people sharing their ideas, even on social media. Together, let’s build the society we want.

I’d like to start by building the healthcare system the American people want, a National Health Program that puts patients before profits and makes corporate health insurance industry middlemen obsolete.

https://tennessean.com…

Paris Dr. Carol Paris is a healthcare activist who currently serves as vice president of Physicians for a National Health Program.

“I Can’t Afford My Oxygen”: The Human Toll of For-Profit Insurance

A veteran physician explains how America’s health system leaves us sicker and poorer.

By Michael Mechanic
Mother Jones, Dec. 16, 2024

Amid the frenzied coverage of UnitedHealthcare CEO Brian Thompson‘s assassination and the public’s troubling reaction to it were references to various polls, including one conducted in 2016 by the Kaiser Family Foundation, whose results suggested that Americans were content with their private health plans.

Similar stats had crept into the debate over Medicare for All—a proposed national health insurance program to cover all Americans, and with which private insurers would have to compete. A few weeks before Thompson was murdered, AHIP, the primary trade group for commercial health insurers, published a new survey it had commissioned. About three-quarters of respondents, a “strong majority,” the group said, were satisfied with their employer-provided plans and preferred getting their coverage this way, as opposed to through any government program.

I found these numbers hard to square with the nonchalant—even celebratory—response to Thompson’s death. Until, that is, I spoke with Ed Weisbart. A veteran medical doctor, now retired, Weisbart serves as national board secretary for Physicians for a National Health Program (PNHP), a nonpartisan organization of some 25,000 doctors founded in 1987 to advocate for a public health insurance program. (Disclosure: My late mother was a member.)

So long as you’re healthy, he told me, it is in your insurer’s best interest to keep you happy by delivering on small claims. It’s only when it looks as though you’re going to cost them lots of money that the denials start coming—and maybe by then you’re too sick to fight. This interview was edited for length and clarity.

What compelled you to join PNHP?

I was a practicing physician for decades and got fed up with seeing patients unable to afford health care—not in the broad, abstract way, but in the very real, nitty-gritty way. The Type 1 diabetic who has uncontrolled disease, and I prescribe insulin for him, and it would make a huge difference in his life expectancy, but he comes back a month later and his blood sugars are no better. And I ask him why, and he would say, “Well, because I’m taking my insulin every other day. It’s all I can afford.” I know he’s barreling toward dialysis.

A patient with end-stage emphysema came into the office without her oxygen, huffing and puffing, unable to breathe. She’s had portable oxygen at home and we know this because she had it previous visits. And I said, “Where’s your oxygen? Why are you so short of breath?” She says, “Oh, I can’t afford my oxygen anymore.”

We’re living in a country where we have people who literally can’t afford to breathe. I’ve got hundreds if not thousands of stories like that. It just drives me crazy, realizing you have to advocate for patients outside of the exam room as well, and then understanding that the reason it’s like this is because of the profiteers just leeching the blood and soul of everyday human beings so they can have the best returns on Wall Street.

What did you make of the reaction to the Brian Thompson killing?

It’s obviously a tragedy and a very wrongheaded move. I was aghast. And yet it was also not hard to understand the dynamics, when there are tens of thousands of people dying because of the profiteering—people constantly running into having some bureaucrat say they can’t get the lifesaving care they need. So, I was not surprised, but I was surprised.

What do you consider the biggest flaws of our health system?

As a medical director at various places, I’d say the biggest problem is that the system is designed to return profits rather than to improve health. And the programs that you would want to design to improve health are contrary to the business model of the people that could put those programs in place.

Related to that is the fragmentation of the system. That’s a consequence of the first problem. It means comprehensive solutions can’t be put in place. It means people are thrust into gaps in between care. So it creates its own set of expenses and driving up the cost.

The third piece is our inability to negotiate prices on behalf of Americans, which other countries do. Those costs are borne all across the system in ways that are obvious, like the overhead of the insurance industry—13 percent to 18 percent depending on where you look. But then they hide more than that by transferring some of the overhead onto hospitals, hospital infrastructure, and medical practices. Milliman estimated the average physician pays $100,000 for office staff to deal with the insurance industry, and where does that money come from? It comes from jacking up prices. All the fee schedules have to be adjusted so physicians can afford to pay this overhead.

This is unique to America. In Canada, the overhead of running a practice to deal with the national health insurance they have there is more like $20,000 or $25,000 per doctor.

In any other industry, auto repair for instance, you get an estimate in advance of what it’ll cost you. Why isn’t that the case with health care?

Well, I would argue that’s not the correct solution, anyway. Because in the auto repair industry, you can shop around and make an intelligent choice, and you know whether the car is going to work right afterward. In health care, it’s the exact opposite.

You can shop for prices for [commodity services like LASIK], but that kind of thing is a tiny fraction. In health care, a very large percentage [of the total cost of care] is spent in the last six months of life by people who are desperately sick, and they are not in a position to start shopping around. And even if you had the prices, how do compare that to quality? If an insurance company with six floors full of actuaries can’t do the price-versus-quality equation so that you they can direct you to the best quality care for the price, how is the person who works at the gas station on the corner supposed to make that determination?

I’m also curious about situations in which a patient gets a crazy bill, just totally unrealistic, and they kick up a fuss and the insurer suddenly reduces the cost or even wipes it out entirely. Is the whole system premised on people giving up and not fighting claim denials?

Yes. There’s data about this for Medicare. If Medicare denies a claim, it’s usually because the claim is for something that’s legally not a covered benefit. It’s extraordinary for it to be any reason other than that, and so when Medicare denies claims—which they almost never do—and someone appeals, there’s about a 1 percent chance that appeal will get reversed.

Now, with Medicare Advantage, which is the for-profit, typically proprietary, insurance industry version of Medicare, its the exact opposite. If somebody appeals a denial, I think around 80 to 85 percent of those denials get reversed, because when Medicare Advantage does a denial it’s because it wasn’t in the company’s business interest to pay for it. But nobody appeals it because they don’t know that they can—or that it would work.

Fascinating. So it’s actually easy—well, not easy, because it’s a total headache—but you can get these things reversed if you persist.

I wouldn’t call it easy by any means. The patient has to spend significant time collecting things and going through the process. And you need a physician who’s willing to help, and who’s going to pay the physician for that? That’s a chunk of the physician’s time that is not reimbursed. Plus, most people in a situation where they need to do that are sick. They’re not at their best to begin with. It’s really hard, really time-consuming. And there’s a long delay from when you do the appeal to when you get a favorable decision.

Tell me more about the for-profit model, and how delaying and denying claims plays into it.

The commercial insurance industry collects a premium. So that’s a prepayment. The Medicare Advantage industry is prepaid by the government. That’s money in their pocket, and every time they pay a claim, that’s money that they’re spending.

They have this term, “medical loss ratio,” which is a carryover from the fire loss ratio and property loss ratio, but they call it a loss when they pay. So, they don’t want to pay, and it manifests in a couple of ways. First, if they don’t pay the claim, that’s money they can retain. Secondly, even if they just delay the care, they have sophisticated systems managing how they invest the money they’re not paying.

I once worked in a part of the insurance world where they did exactly that. They had contracts that required them to pay their bills within a certain timeframe, and if they paid long after they were contractually obliged to, there was a penalty, and they had sophisticated systems to analyze the return on their investments in the market vs. how big the penalties are for delaying the payment for care. And they would delay until they hit the right point on the curve where it was more sensible financially to pay the claim than to keep investing it in the market.

So basically you collect a big pile of money and invest it and then avoid paying claims so you can keep that money invested as long as possible to maximize your returns in the market?

That’s exactly right.

What are the kinds of procedures insurers are most likely to deny or delay, and the most common reasons people fall into medical debt?

I can’t give you a quantitative answer, but the more expensive a procedure is, the more likely they are to want to put in a barrier to payment. Insurers typically don’t want to put barriers to things that low-expense patients get, like a blood pressure medication that’s very inexpensive and that healthier populations use. It’s to their advantage to get you to use the insurance a little bit because the people that are the most likely to disenroll from a specific company are the people who never use it. They want you to maybe get your eyeglasses or something.

But if you’re sick and you need home oxygen, or you need a CT scan or an MRI, or something that’s both expensive and predictive that you’re probably a higher risk person—that you’re going to be a more expensive patient to take care of—they don’t want to spend that money. So if you call them and say, “I’m so mad at you. You got in the way of my CT scan. I’m thinking of going to different insurance company,” the company has a win! They don’t want you in their plan.

You mention CT scans. I know imaging is among the things medical practices tend to overprescribe because it’s a cash cow, and you get a fair bit excessive testing and overtreatment. Can certain denials then be to a patient’s benefit?

There is obviously a significant percentage of what we do in medicine that is not evidence-based and could probably be avoided. But if you compare the United States to other modern nations, our utilization of those kinds of services is roughly average. The problem with the high cost of care in the US is not overutilization. Is there overutilization? Absolutely. Is that the driver of health care costs? No, it’s not.

The driver of health care costs is two things: It’s the overhead, the managing, the cost of the complexity of administering this. Most estimates are that we spend roughly a third of the health care dollar propping up the bloated, Byzantine insurance industry. The second piece is the failure to negotiate prices effectively because we’re so fragmented. That’s where the money is.

How big a cost is the failure to negotiate prices?

I can’t tell you overall, but the average prescription drug in the United States is about twice as expensive as it is in the rest of the modern world.

How does the cost of a public insurance bureaucracy compare with the cost of a private one?

The commercial insurance industry has a roughly 15 percent overhead. Traditional Medicare, parts A and B, operates with a roughly 2 percent overhead.

Wendell Potter, a former Cigna PR guy, just wrote a Bloomberg piece on the role of Wall Street, and how executives at giants like UnitedHealthcare and Cigna go to these investor conferences where there’s no mention at all of patient care. It’s all about the returns, and that’s what’s driving a lot of the misery we’re seeing.

Oh, that’s exactly right. I mean, the root issue is greed.

But don’t public systems also have their drawbacks? The Veterans Administration has weathered scandals. And I saw a CTV News piece from last fall about how Canadians fed up with long wait times for surgeries in their public system were turning to private providers.

If you go down the street in Canada and ask people, they all have a story like that. But then they’ll say, “But there’s no way I would change to the United States system where I have to have a bake sale to have my knee replaced.” They don’t want this system.

More importantly, US life expectancies were the same as Canadian life expectancies within a few months up until the early 1970s. That’s when we passed the HMO Act, creating managed care, and Canada finally finished implementing their national health insurance plan, and then there was a fork in the road. Our costs continued to go up along the same curve. Their costs started to really flatten out, and our life expectancy did not begin to keep pace with the improvements in life expectancy in Canada. Fifty-some years later, they live three to five years longer than we do and spend half as much.

Have you seen any notable pivot points for the United States in terms of the cost of care and deterioration of quality?

They’ve been on a steady, relentless curve. There’s a whole list of things that we have tried, and none have really bent the curve. There’s one obvious solution.

You mean single-payer?

Correct. But I’m not stupid enough to say that sometime in the next four years or six years that’s going to magically pass. One of the things PNHP has been really good about the last three or four years is thinking about a strategy of how do we pave the road to that? What has to happen? Our strategy to get the bills passed is far more robust than just pass the bill. The single-payer community five years ago, 10 years ago, would literally say you can only cross a chasm in a single leap. You know, I’ve looked at the bottom of chasms and there’s dead people who couldn’t make the jump. You cross the chasm by building a bridge slowly.

Do you think for-profit insurers play any positive role in our system, or would you like to see them go away entirely?

I would like to see them go away entirely.

I mean, it’s probably never going to happen here.

Everything looks impossible until it’s already happened.

My skepticism comes from watching Obama try to implement single-payer and having it demonized as socialism—and “death panels” and so forth.

I don’t think people care whether it’s single payer or quadruple payer. Those words mean nothing to people. You know, Medicare for All. That’s not what they care about. People want health care. They don’t care about health insurance. They’re angry at the profiteering, the outrageous prices. They’re angry they can’t afford their care. They’re much more focused on solve this problem than they are on which exact tool or mechanism you go to.

That’s what I think, too. What I care about is that everybody in the country has unfettered access to high-quality health care that they control the decisions for. I think single-payer is the smartest way to do it. But if we went to an “all payer” or some other model that accomplished that, I’m fine. I just don’t want people dying like they are today.

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