Ripping off the system, one patient at a time

This week, I attempted to do what consumers world over try to do: figure out the cost of a transaction to make an informed decision before I acted. Everyone from market shoppers in Malawi to mega-billionaires choosing to invest their capital does this. They all are promoting their self-interest and also trying to save or even make money.

I wanted to know what a doctor’s visit would cost and how much truly might be or might not be covered. If needed, I wanted to know if I had to find a better bargain, if the first option would not be an affordable activity with my plan. It might have been easier to walk across the Sahara barefoot, without water.

What I tried to do is impossible for American consumers trying to figure out the price of just about every medical procedure, doctor’s or dentist’s visit, and hospital activity.

Photo courtesy of Harvard, showing people protesting for health care access. But most of us want health pricing information too, and are prevented from getting that by providers and insurance companies.
Photo courtesy of Harvard, showing people protesting for health care access. But most of us want health pricing information too, and are prevented from getting that by providers and insurance companies.

Today, except the for very rich who do not need insurance, there is no such thing as a functioning U.S. health care market, where consumers can freely choose to pick their providers and choose lower-cost options. Insurance companies and providers do everything possible to hide prices and bully and even threaten insured consumers who are trying to make choices that occur in rational and functioning markets.

The Commonwealth Fund notes, “… the U.S. health care market is unlike any other market: patients rarely know what they’ll pay for services until they’ve received them; health care providers bill different payers different prices for the same services; and privately insured patients pay more to subsidize the shortfalls left by uninsured patients. What’s more, prices for health services vary significantly among providers, even for common procedures such as laboratory tests or mammograms, although there’s no consistent evidence showing that higher prices are linked to higher quality.”

The Commonwealth Fund argues that even some modest reforms in pricing transparency, with our broken system, could lead consumers to “receive high-quality services from lower-cost providers … This, in turn, could encourage competition among providers based on the value of care—not just on reputation and market share.”

So what does this have to do with me and my experience? Everything, actually.

Gauging consumers one by one: the thousand cuts approach:

For years, I have consistently tried to get dentists and doctors to give me a price quote before a visit. To date, I have never had any medical provider provide me prices or codes without fighting tooth and nail, and often it is with caveats that claim they are exempt from any responsibility if their pricing information is wrong, even with the diagnosis code for a routine checkup.

Here is how the health provider and health insurance fraud and rip-offs work, patient by patient, and this is how it recently happened with me.

Step one: Call the provider and have them evade sharing information.

  • “We can’t provide you a diagnosis code until you see the physician.” To which I reply, “I am trying to understand if the charge will be covered by my insurance company.” They answer, “We can’t do that because the doctor may do [fill the BS line that you prefer].”

Step two: Call the insurance company and have them not tell you if a possible charge by a provider is within their “usual and customary charges”—a term that is behind a wall of secrecy and never shared with consumers, ever.

  • “Hello, I’m trying to determine if my visit to my physician is covered and if the charges are within your accepted ranges.” They reply, “Sir, we can’t do that. We’d need to know the diagnosis codes and procedure codes before we can possibly investigate that.”
  • To which I reply, “Sir/mam, I don’t have that. Doctors’ offices never tell you that. I don’t have the codes.” Or, if I was able to get a code for a check up, “Here is the diagnosis code [fill in code], what is your accepted charge.”
  • The reply could be, “Sir, I told you we would need the diagnosis code to investigate…” Me interrupting, “Sir/mam, I just told you they won’t give me that code, and no doctor…” Them interrupting, “Sir, you are becoming agitated, stop interrupting me. I was saying we need the diagnosis….” Me interrupting, “I am not becoming agitated. I am behaving perfectly rationally. I just want to know what this will cost and how it will be covered.”
  • They reply, “Sir, I have already told you, without a diagnosis code and procedure code, we are not able to provide you…” Me interrupting again, “Sir/mom, did you just hear me when I said the office will not provide me with a diagnosis code.”

Usually such a song and dance can go on for about five or 10 minutes. In the end, the insurance reps will likely have bullied the consumer and employed their standard and tested propaganda that justifies preventing nearly all consumers from knowing if any medical procedure will truly be covered and at what level. The same works for hospitals, clinics, and other practices, who will not share their prices.

In short, they have created a system that perpetuates waste, fraud, and abuse, one patient at a time, systemwide—and it is a system that remains protected by powerful special and political interests who profit from this.

Who the hell created this mess and what it means:

We can thank our political process that encourages special interests to buy influence and bankroll candidates with campaign donations for a good chunk of this mess. We can also thank the so-called health insurance companies from protecting their market share that makes the United States the most inefficient and most expensive health care system among all developed nations.

The Commonwealth Fund in 2014 reported the U.S. trailed other developing nations in health care outcomes and costs.
The Commonwealth Fund in 2014 reported the U.S. trailed other developing nations in health care outcomes and costs.

The Commonwealth Fund also has found that the U.S. system underperforms and has worse outcomes than 10 other industrial nations, mirroring past findings. No surprises there—this fact has been reported by health and public health researchers now for years. The U.S. economy devotes an absurd 17.7 percent of GPD to health care spending, almost double that of its peers.

How the United States compares to its peers in health care spending by GPD. Source: Commonwealth Fund.
How the United States compares to its peers in health care spending by GPD. Source: Commonwealth Fund.

The Center for American Progress has described the consolidation of power by the bloated middlemen of our dysfunctional health care system as a crisis, due to consolidation and market control. The center reports the “lack of competition has led to growing insurer profits, increased costs and reduced coverage for enrollees, an epidemic of deceptive and fraudulent conduct, and rapidly escalating costs.”

Theodore Roosevelt in 1912 led one of the earliest efforts to support a national health plan in the United States, and received support from progressives at the National Progressive convention that year.
Theodore Roosevelt in 1912 led one of the earliest efforts to support a national health plan in the United States, and received support from progressives at the National Progressive convention that year.

From the early 1900s to the present, major efforts to reform the U.S. health care system to create a national health system have failed. Some of the principal profiteers that have safeguarded the status quo are the monolithic health insurance companies, like Premera Blue Cross, my provider.

Other bloated health benefits providers include Aetna, Wellpoint, UnitedHealth Group, Cigna MetLife, and Humana. All of these companies are major political players who donate generously to members of Congress and state officials.

The health insurance model is a system vigorously defended by the GOP-controlled Congress, whose members theoretically support open markets, when in fact GOP members have attempted to derail the Affordable Care Act more than 50 times as of January 2015. And that reform was ultimately about reforming the existing health insurance market, not changing the system to promote openness in pricing or improving population health that is linked to universal health care systems.

The ACA only offered modest efforts to promote transparency. The law requires hospitals to publish and annually update a list of standard charges for their services. Other provisions about requiring exchanges to show prices are at best failed and complicated efforts that do nothing to break the wall of secrecy that has fed the beast that is our health insurance market.

The most pathetic part of this is, when I as a consumer try to do something, I am labeled a problem and seen as the bad guy. But I am OK with that, because doing the right thing always will meet with resistance. I have never kissed a doctor’s feet or behind, or those of companies that profit through monopolistic practices. I do not intend to start now. It just rubs me that today when I see the doctor, and tell him to make his pricing transparent, he will roll his eyes and give that “whatever look.”

Latino voters’ strong support of healthcare reform overlooked in electoral analysis

A week has passed since President Barack Obama handily defeated Republican challenger Mitt Romney in the Electoral College count  (332-206) for the office of the presidency. While Obama grabbed approximately 61 million votes compared to Romney’s roughly 58 million, he trounced him among Latino voters. And their decisive backing of the incumbent Democrat by a margin of 71% to 27% can be credited greatly to Latinos’ strong support of the administration’s signature health care/health insurance reform known as the Affordability Care Act (ACA).

Latinos’ support for healthcare reform dates back to the 2008 election, captured so joyously in this pro-Obama video that calls out Obama’s “plan de salud.” (I love this video, and want to hire this band for my first run for office if I ever do that.)

The Pew Center calculated the wide margin by which President Barack Obama defeated challenger Mitt Romney among Latino voters.

In November 2011, exactly a year before the 2012 general election, Univision/Latino Decisions polled 1,000 Latinos (ME +/- 3.1%) and asked them how they viewed the role of government in ensuring that everyone had access to healthcare, or whether people should be responsible for their own health insurance. The question served, in short, as a proxy on how this block of potential voters viewed the national debate on healthcare. At the time, the ACA was vehemently opposed by the GOP, healthcare and business interest groups, nearly half of the country’s GOP governors, the GOP majority of the U.S. House of Representatives, and most importantly future Republican Party standard bearer Mitt Romney.

In that poll, those favoring government-led healthcare numbered 59% compared to those favoring individual insurance at 29%. Half of those polled answered that they believed Democrats were closer to their position on healthcare compared to Republicans, at a paltry 18%.

At that time, 12 months prior to the general election, the top issue among potential Latino voters was the economy, overwhelmingly, at 40%, but the No. 4 issue was healthcare, at 16%.

On election night on Nov. 6, and in the days following the election, the blogosphere and pundits of all stripes prognosticated on how poorly the Republican Party courted the crucial and incredibly diverse Latino electorate. The group includes those self-identifying as whites and non-whites, Mexican and Central Americans, Cubans, South Americans, Dominicans, and others. The group harbors great economic diversity as well.

ABC News’ Nov. 7 coverage was typical: “Mitt Romney and the Republican Party’s tremendous difficulty appealing to Latino voters dealt a significant blow to their chances of winning in 2012.” Many of the experts suggested that Romney’s campaign miscalculated during the primary when he swung hard right and said he would support “self-deportation.” Such statements, go the conventional wisdom, explain why most of the Latino’s 10% share of the national voting electorate favored Obama. (Numerous media outlets reported that it was the first time since 1996 that a Democratic challenger had won such a high percentage of the Hispanic vote; President Bill Clinton in 1996 grabbed 72% of the Hispanic vote.)

Healthcare issue ignored in the Latino election narrative

Was Mitt Romney “done in” by Latinos or “done in” by vehemently opposing healthcare reform overwhelmingly supported by Latino voters?

Of course this simplistic analysis doesn’t fully explain why Latinos would trust Obama, when his administration was on record as deporting 1.5 times (yes 1.5 times) more immigrants per month than the previous administration of George W. Bush. As of July 2012, according to the Washington Post, the Obama administration had deported 1.4 million immigrants, allegedly targeting dangerous criminals. While Obama’s team mounted a legal challenge to Arizona’s harsh anti-immigrant law and provided a limited amnesty program to offer limited but not permanent amnesty to nearly 800,000 young immigrant residents in July 2012, his administration’s anti-immigrant actions also clearly alarmed many Latino residents and voters.

So why did they fall so completely and totally for  Obama and Vice President Joe Biden over Romney and his running mate Paul Ryan? Clearly, healthcare mattered, and it mattered more than the media has acknowledged. The election was also a very clear referendum on national healthcare reform that Romney and Ryan pledged to dismantle if they won.

In a September 2012 speech to the U.S. Hispanic Chamber of Commerce, Romney stated his agenda clearly: “Obamacare is the wrong way to go … . I will repeal and replace Obamacare with reforms that increase choice, slow down the runaway growth of insurance costs, and open the door to more new jobs.”

Such messages completely flew in the face of what Latino voters wanted – a government-led, national healthcare plan. On Nov. 6, Latino Decisions’ election eve poll of 5,600 voters reported virtually unchanged numbers among Latino voters from the poll a year earlier.

The respected polling organization again found healthcare to be the No. 4 issue among the diverse Latino electorate, behind the economy, education, and immigration. The poll virtually repeated numbers found a year earlier, showing 61% of respondents favored leaving healthcare reform in place.

Latino Decisions’ Matt Barreto reportedly told USA Today that from the beginning of the Romney campaign “the most obvious miscue” between Romney and Latino voters was his continued attack on the ACA.

What remains puzzling is why so many media organizations completely ignore that Latino voters, like the majority of the voting public, supported the administration in a clear national referendum on healthcare reform that the GOP, GOP surrogates, many parts of the all-powerful healthcare industry, special and business interest groups opposed with nearly obsessive and feral passion.

The matter is settled, both by the highest court in the land and now by the ballot box. The opponents of the ACA — the market-oriented, limited healthcare reform that was passed by Congress — lost, and they lost decisively. Latinos voters, who so clearly supported the legislation, made that clear as a bell on election night in completely rejecting the GOP, its anti-healthcare reform message, and the former Massachusetts governor.

A primer on the futility of buying health insurance in the open market

On Sept. 19, my University of Washington graduate student health insurance plan expires. I paid $607 a quarter last year, four quarters a year, for two years for this plan. It was OK. I never really “used” it for anything. I did have my knee looked at, and a finger was inspected once that got dislocated that I actually fixed, but no real “medical care” was ever provided except consultation. Only one visit really required a specialist’s expert analysis, but I actually deduced a similar conclusion from online research. Short of a medical test, even that expert opinion was just that, an opinion. So I am left wondering what this investment served. It did not cover in-house physical therapy, massage, or chiropractic care—all forms of medical care that I truly believe promote health and wellness without expensive, harmful pharmaceuticals and that use non-invasive techniques to promote healing through touch and manipulation of the body’s muscles and skeletal system.

Massage should be covered at higher levels by all insurance plans, as it provides excellent health outcomes with few negative effects and no medication.

I was supposed to cover those expenses “out of network” at 60%. As a former graduate student, I had to weigh medical care versus, well, paying for food and rent, and I simply put off the care I needed the most and used to get when I had a plan with my former employer in Alaska – chiropractic care and massage therapy. There were times I was in excruciating pain that simply had to be ignored because my insurance did not cover it, and those problems could have been addressed if I paid for much of it, after my deductible.

So now I am in the open market of insurance again. This is that wonderful place where the “invisible hand” of Adam Smith is supposed to provide solutions without “government interference.” Well that is not the case. The market is somewhat regulated by the Washington State Insurance Commissioner. They put together a good web site to help consumers understand the nine companies that offer health insurance plans in this state and the types of plans available to them. I think they did a good job.

Such communication for consumers is critical, as insurance companies prefer to communicate in “insurance speak” language involving legalese and jargon such as “co-pays,” “deductibles,”  and let’s not forget “pre-existing conditions.” Here’s just a taste of one clause from one plan on how they try to limit coverage for a “pre-existing condition”:  “Pre-existing conditions: these plans contain a nine-month pre-existing condition clause that excludes coverage for any condition for which there has been diagnosis, treatment (including prescribed drugs), or medical advice within the six-month period prior to the effective date of coverage, for which a prudent person would have sought advice or treatment. Section 6 of the application for our individual and family plans will help us determine whether you have creditable coverage, which would allow [COMPANY NAME REMOVED BY AUTHOR] to waive pre-existing conditions/exclusions for you and/or your dependent(s).

No, choosing insurance is never easy because the language is often confusing and many non-experts cannot decipher the fine print of the  brochures with happy, smiling people used to lure in customers.

Such language is not simple or easy to understand, and in theory, the Patient Protection and Affordability Care Act (health insurance reform passed by Congress recently) will make it impossible for insurance companies to deny persons health insurance in the future because of a pre-existing condition. It is not clear if non-English speakers can understand this information at all. While many people have fought with insurance companies, many lower-income or less-educated persons may not have significant experience navigating complex legal documents that, quite frankly, I think people with MBAs or law degrees do not fully understand. Here are two companies’ plans that offer health insurance to individuals in the state of Washington (there are exactly nine corporate players in this limited market): LifeWise, Group Health.

I chose LifeWise. I am waiting for them to approve my plan. I will have to have proven I actually had coverage before (I did as my UW plan was owned by them) and am likely not a deadbeat. I am sure they are probing my legal, credit, even personal records as I write this to determine if I have been an actuarial risk to providers, if I have some terrible health condition that would harm their profit margins, and if I am generally on the up and up as a possible customer to help them make a “reasonable rate of return,” which is really all a company can hope to do. This all is, of course, unlike other developed democracies, because our country continues to refuse to adopt a single payer plan that other countries like Canada and France have taken up with better population health outcomes for their citizens and less gauging of consumers.

So what will I get if I am approved? I signed up for the basic catastrophic plan called “Wise Simplicity”. I would pay $160 month as a nonsmoker, and have a $10,000 deductible (compared to an $1,880 deductible that would cost me about $370 a month). So if I am hit by a car, I pick up the first $10,000 out of pocket? Great, eh?

So what do I get with the barebones plan? Well, basically a plan that tells me not to get sick and certainly don’t have an accident that costs $9,999.

I simply cannot afford another plan now. And this deeply worries me, until I get a job with coverage (and that is coming soon – yeah!). Two people I know in my immediate circle of friends just had enormous medical bills. One friend had elective knee replacement surgery. I cannot imagine that is less than $50,000 to $100,000 in costs (surgeon, anesthesiologist, several nurses, equipment, rehab, etc.). Another friend had a horrible and likely allergic reaction to a standard immunization and developed a syndrome that sent them to the hospital, where the same issue ensued with specialists, etc. My friend guessed the bills before insurance will be at least $100,000. So as I bike down Seattle’s dangerous roads, avoiding cars that do not know I am there as the driver texts a message about whatever, I contemplate just how flimsy my health care coverage really will be come Sept. 20. I guess the answer is what some running for office suggest – just don’t get sick. You know what I really do not have a choice. Adam Smith’s invisible hand I guess is making that possible, but why do I feel more like the hand is choking off my air supply and giving me a sucker punch when I am not looking.

My new occupation, public health wizard, if the high court declares health reform unconstitutional?

So, less than 24 hours before the momentous decision of the conservative leaning U.S. Supreme Court on the constitutionality of the Patient Protection and Affordability Care Act (ACA), I am hearing almost no public discussion or reading any popular media addressing moral issues.

If the Supreme Court strikes down health care reform, should public health practitioners go to Hogwarts to learn magic, so they can solve public health problems with wands and spells and not actual resources, namely money?

Instead, we are hearing legal scholars discuss what time of the morning the justices come into the chamber, or whether the so-called individual mandate, which would compel every American to buy health insurance in the private market, is permissible under the Commerce Clause doctrine. We are getting detailed accounts of the ways the court might go on key issues, such as Medicaid’s expansion to have the federal government expand coverage to persons 133% above the federal poverty level and if the lawsuit by 26 states attorney Generals is valid before the law can be implemented. And so on and so forth, go very learned people trying to make sense of a complicated case.

What we are not hearing enough of are discussions about how many millions of Americans remain uninsured, and the costs associated with doing nothing to address that crisis. (The U.S. Census Bureau pegs the number at 50 million.) We are hearing next to nothing about the historic efforts that have prevented this nation from adopting a national health care system like other modern, capitalist democracies such as Canada, Taiwan, Japan, and France (see this comparison of how the United States system is different than and similar to other national systems, but still less efficient and more expensive). I suppose we are not getting this rehash because our nation already had that spasm of coverage during the debate before the passage of the ACA in Congress along strictly party lines in March 2010.

So in this vortex of news distortion without perspective, I would recommend that anyone who wants to get a grasp of the “bigger story” about the essential inequity and deficiencies in the U.S. health system read T.R. Reid’s clearly written tome called The Healing of America, the book I read before I began my studies in public health in 2010. In his 2009 analysis of health care systems in France, Germany, Japan, the UK, Canada, India, Switzerland, and Taiwan, Reid finds we are doing far worse in the United States, paying more money, and living less healthy lives, despite the false propaganda that we have the “best health care system in the world.” You can see a summary of the other national models here. I am not the first person to point out that learned persons, such as the 12 justices who will rule on June 28, 2012, should read this book.

Reid notes, in an article that draws from what he outlines in his book: “The world champion at controlling medical costs is Japan, even though its aging population is a profligate consumer of medical care. On average, the Japanese go to the doctor 15 times a year, three times the U.S. rate. They have twice as many MRI scans and X-rays. Quality is high; life expectancy and recovery rates for major diseases are better than in the United States. And yet Japan spends about $3,400 per person annually on health care; the United States spends more than $7,000.”

Reid points out the immorality that is our patchwork system of universal care (the Department of Veterans Affairs for military personnel), subsidized care for the poor and elderly (Medicare and Medicaid), and privatized care, if you have an employer in most cases. It is immoral because it still leaves out millions of Americans, which the very imperfect ACA, after intense lobbying to pre-empt a single payer system and scuttle any discussion of a national health plan, tried to address by using market mechanisms (the individual mandate). According to Reid, “Every developed country except the United States has designed a health care system that covers every resident. … Covering everybody in a unified system creates a powerful political dynamic for managing the cost of health care … Universal coverage also enhances health care results by improving the overall health of a nation.”

So again we are failing to discuss the main issue here, which is a moral one. Health care, argue many medical and religious leaders, is not purely a political issue, but a moral right. I will leave this post with a very clearly stated summary from the group called Physicians for a National Health Program, an 18,000-member organization dedicated to the creation of a national single-payer health program. The organization states: “The U.S. spends twice as much as other industrialized nations on health care, $8,160 per capita. Yet our system performs poorly in comparison and still leaves 50 million without health coverage and millions more inadequately covered. This is because private insurance bureaucracy and paperwork consume one-third (31 percent) of every health care dollar. Streamlining payment through a single nonprofit payer would save more than $400 billion per year, enough to provide comprehensive, high-quality coverage for all Americans.” I could not have said it better myself.

As for me, I was contemplating a bit of street theater downtown on June 28, but perhaps in my laziness I did not execute the costume and plan. Maybe later, when we learn about the implications of the Supreme Court’s decision, I will dress up as a public health wizard, like Harry Potter and his pals at Hogwarts. Then, I will recite magic phrases and wave my wand and cast spells to cure people and pay their medical bills, without of course actually doing something to fix what is ailing our political and health care systems that continue to leave our nation dragging behind other countries by all measures. That may actually be a job in demand, because if the ACA is struck down, a lot of public health interventions will no longer be funded, and our nation’s health will be worse because of it.