Saturday, June 24, 2017

What is the Role of Insurance in Healthcare?

With the U.S. Senate snarking over a so-called replacement for the Affordable Care Act this week, and with all the talk anyway about the Affordable Care Act's success or failure, and the Republicans in Congress determined to get rid of it, maybe it's time to ask the question: What is the role of insurance in healthcare?

What does "healthcare" mean in America nowadays? Here's my understanding, based on my personal experience. I'll use myself, in fact, as the example. I develop physical symptoms that will not go away on their own or respond to my diligent self-care treatments. So I call my primary physician and make an appointment. When I go in to see my doctor, I provide updated information on what medications I'm taking, and any changes that may have occurred in my medical history such as a recent surgery. My doctor and I meet in an exam room.  I describe to her my symptoms. She gives me a physical exam around the symptoms to try to determine a cause. Doctors try to figure out not only if they're dealing with a disease process but also what the cause might be in order to prescribe the best treatment. My doctor's really smart. She figures out not only the disease but the cause and prescribes a medication that clears up the problem in two weeks.  This is healthcare.

Before about 1973, at this point, most people paid the doctor's bill and the pharmacy bill themselves. The costs were affordable. Insurance was for catastrophic costs such as for hospitalizations, cancer treatment, and surgery. After Congress passed legislation in 1973 that allowed insurance companies to make a profit, as I understand it, the insurance industry began to go after more business and offering more coverage possibilities.

Now, it's gotten more and more difficult to pay out of pocket for a doctor visit, for a medication, or for an X-ray. It's the same with dentists, also. And so the insurance industry steps in and offers to pay...for a price. That price may have nothing to do with healthcare but with control of access to healthcare.

This morning, I spotted a full-page ad in a magazine from a very large medical insurance company that will remain unidentified at this point. The ad copy (I used to write ad copy, by the way) talks about "helping" with both the challenges and opportunities of health care. Let's take a look at the specific ways the insurance company plans to help:
  • This company offers to provide "employers with data and insights that can improve health outcomes." I wonder what employers they have in mind.  Doctors? Because to my mind, doctors are the people who'd be interested in data regarding health outcomes, not, say, a company like a book publisher or convenience store chain. So what exactly is the insurance company saying?  That they have control over health outcomes? They could if they had control over who they covered and what they allowed as treatment. I suppose if they are interested in being the insurance company that covers a book publisher's employees, the book publisher would want to keep health insurance costs down, right? So the insurance company would give them different options to do that, right? Then provide the "data and insights" about how that's working out for them. This ultimately means that the insurance company will get involved in decision-making regarding treatments in order to keep costs down. Control.
  • The company says in the ad that they'll ensure "seniors have stability and choice in their benefits." Hmmmm. Medicare? Well, nowadays, private insurers offer Medicare plans with the blessing of Medicare. This makes me wonder why insurance companies are so against single-payer insurance when they're already involved with it. Once single-payer insurance was established, private insurers could transition to be the administrators in their areas. But then there goes the possibility of profit! And control. So they are very interested in maintaining the status quo.
  • Finally, they say they'll work "with governments to expand access to care, lower health care costs and improve quality." The first thing that leaps out at me about this point is that the word government is plural. Which governments? In other countries besides the US? They will expand access to care. That's a laugh. Not if they want to keep costs down. What insurance companies have been doing lately to keep costs down is to restrict access to care with networks and formularies and prior authorizations required. I already have experience with their "expertise" in lowering health care costs. Their methods involve denying coverage of medications, doctors, hospitals, and procedures; and doing everything they can to attract healthy people in order not to have to pay out claims.
The last paragraph in this ad is addressed to all who have "a passion to improve health care."  Well, you'd think that'd mean doctors and other medical professionals, right? But I suspect insurers are not at all concerned about working with medical professionals to improve health care.  They haven't addressed this ad to medical professionals.  They've addressed the ad to employers, seniors, and governments. I find it astonishing that a medical insurance company would place such an ad in the first place.



Americans need to establish what they want regarding help with their health care costs. Do they want an insurance company whose priority is their bottom line to make health care decisions for them? Or do they want health care decisions to remain where they belong -- doctors and patients?  If insurance companies could help by negotiating for lower costs from pharmaceutical companies, that would be a huge step in the right direction.  As it stands now, private insurers just drop a drug they don't want to pay for from their drug formularies.

How did medical costs get so high? Actually how did the costs of everything get so high?  Should medicine be a for-profit business in any part? I suspect that if pharmaceuticals is for-profit, that drives the cost increases in other areas of medicine. The bottom line is that the issue is not the Affordable Care Act. The issue is a for-profit insurance industry.

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