JustCare

Tag: Health insurance

  • 2022: Health care costs threaten the well-being of many Americans

    2022: Health care costs threaten the well-being of many Americans

    Fewer Americans are uninsured than ever–almost half the number before the Affordable Care Act took effect. But, rates of underinsurance are high, with millions of people having gaps in their coverage, millions skipping care and millions falling into medical debt because they cannot pay their health care bills. The Commonwealth Fund surveyed Americans and found that, too often, health care costs threaten their well-being.

    The big takeaways:

    • More than four in ten adults under 65 (43 percent) did not have adequate health insurance. People without insurance, people with gaps in insurance coverage during the year, and people who could not afford their care are included in this group.
    • Nearly three in ten people with employer coverage (29 percent) and more than four in ten people with coverage they bought in the individual market (44 percent) were underinsured.
    • Close to half of all people (46 percent) said that they had not gotten care or delayed getting care because of the cost. More than four in ten (42 percent) struggled to pay medical bills or were in medical debt.
    • Half of people surveyed (49 percent) said they could not afford to pay an unexpected medical bill of $1, 000 within 30 days, primarily people with low incomes (68 percent), Black adults (69 percent), and Latin/Hispanic adults (63 percent).

    Large numbers believe health care costs should be a top priority for the Biden administration and Congress. Democrats (68 percent), Independents (55 percent), and Republicans (46 percent).

    “Underinsured” is defined for people living above twice the federal poverty level as out-of-pocket health care costs over 12 months, excluding premiums, representing at least 10 percent of household income and for people living under twice the federal poverty level, representing at least 5 percent of household income ($27,180 for an individual and $55,500 for a family of four in 2022). Or, people whose health care deductible represented at least five percent of household income.

    People who lacked health insurance for at least a year tended to be young, poor, with one or more chronic conditions, living in the South, Latin/Hispanic. Undocumented individuals are not able to get affordable coverage.

    Because the US lacks a national health insurance program or even a national health insurance enrollment program, a lot of people who might be eligible for coverage based on their age, income and needs, go without coverage. More than half the people surveyed (56 percent) who had employer coverage but had been uninsured at some point during the year did not know that they were eligible to enroll in their state health insurance exchange plans because they lost their coverage.

    Americans likely would pay a lot less for their health care if the government set rates for all health care providers, as it does for people with Medicare. Because the US does not set provider rates–as all other wealthy countries do–these high rates drive high cost-sharing. Physician and hospital prices in the US are higher than anywhere else in the world.

    Close to one in four people with chronic conditions, such as diabetes, are not filling their prescriptions regularly because of the out-of-pocket cost.

    Of note, nearly one in four people with bills in collection said the bills stemmed from a mistake in billing. More than half of people with medical debt (56 percent) owed at least $2,000.

    Medical bills from out-of-network doctors at in-network hospitals represented almost half of all cost issues. These surprise bills are no longer permissible under the No Surprises Act, which took effect January 2022. But, the survey included a timeframe before then.

    When the public health emergency is declared over, likely in 2023, states will lose their improved federal matching funds. Inevitably, with less money, they will reconsider Medicaid eligibility and restrict coverage.

    Here’s more from Just Care:

  • Health care prices are rising, but not for Medicare

    Health care prices are rising, but not for Medicare

    A new report by Altarum reveals that health care prices are once again increasing, for private payers, though not for Medicare. If there’s any good news for working people it’s that health care prices are not up as much as inflation.

    If you’re not yet on Medicare, you’re likely to face higher premiums and/or out-of-pocket costs beginning in 2023. Right now, health care prices are up nearly five percent, whereas overall prices are up 8.5 percent. So, your health insurance costs might not rise as much as your costs for housing and food, but given how high premiums are already, even a five percent increase could mean $420 or more a year in additional costs.

    If you look at the data over the last couple of decades, health care prices are up way more than prices overall. Over the last 22 years, health care prices have more than doubled, up 110.3 percent. Overall, prices have climbed 71 percent.

    What’s interesting is that Medicare prices dropped by nearly one percent in July, below where they were 18 months ago. Medicare did not raise provider rates for either hospitals or physicians. In stark contrast, private payers have seen a 7.2 percent increase in hospital prices over that time span.

    The Medicare Advantage factor: Altarum is focused on the prices the government sets for providers and not the prices that Medicare Advantage plans pay. Historically, Medicare Advantage plans have paid providers about what traditional Medicare pays. They can effectively piggyback off of Medicare rates. But, we are now beginning to see higher Medicare Advantage payments to some providers, including dialysis facilities and that could be a harbinger for higher costs in Medicare Advantage.

    The federal government should be setting Medicare Advantage provider rates at the same level as traditional Medicare and not wasting federal tax dollars allowing Medicare Advantage plans to negotiate their own rates. To the extent they get lower rates, they are more than likely contracting with l0w-quality providers, as Medicare rates are already significantly lower than commercial insurers. To the extent they pay higher rates, they are driving up Medicare spending needlessly.

    Here’s more from Just Care:

  • States plan to ensure access to top cancer care providers

    States plan to ensure access to top cancer care providers

    Kara Hartnett writes for Modern Healthcare on two states that plan to ensure access to top cancer providers for their low-income residents. To date, Medicaid and state health insurance exchange plans, not unlike a lot of Medicare Advantage plans, do not include National Cancer Institute providers in their networks. New York and California are putting an end to this health inequity.

    Under new laws in both New York and California, insurance companies will have to work out a payment arrangement with National Cancer Institute Cancer Centers. The New York law went into effect in April. The California law is expected to go into effect in January 2023.

    What does this mean? If you live in New York City and your insurance is through Medicaid or a NY state health insurance exchange plan, you will be covered for care from Memorial Sloan-Kettering Cancer Center.

    These two state laws will help promote health equity for people with low incomes, people of color, and other people who otherwise would not have access to care from a cancer center of excellence. And, they make sense. Why should insurers be allowed to contract with low-value providers and not be required to contract with high-value providers?

    Insurers should not be allowed to keep enrollees from getting their care from centers of excellence. To date, Medicare Advantage plans have had free rein to restrict access to these centers for their enrollees. It’s how they save money–while likely jeopardizing the health and well-being of their enrollees.

    The federal government should step in to stop insurers from designing their own provider networks, particularly in Medicare and Medicaid, where the government negotiates provider rates. Networks make no sense in Medicare Advantage, as Medicare Advantage plans can piggyback off of traditional Medicare provider rates. They don’t need a network to bring down provider rates. The only purpose the network serves is to keep people with complex conditions from getting care from the specialists they need to see.

    What’s worse for people in Medicare Advantage plans is that the federal government has no way to ensure that network providers are adequate to meet enrollee needs. While there are Medicare Advantage rules in place regarding time and distance, the rules do not include provider availability. That aside, for years, the Medicare Advantage plans issue provider directories filled with misleading information, and the federal government has not held them accountable for misleading their enrollees.

    Here’s more from Just Care:

  • Expect high out-of-pocket costs if you’re hospitalized, with insurance–and fight them

    Expect high out-of-pocket costs if you’re hospitalized, with insurance–and fight them

    Michael Levenson reports for the New York Times on a woman who had to go to court to avoid paying hundreds of thousands of out-of-pocket health care costs. The woman, Lisa Melody French, went to her local hospital for back surgery. The hospital told her to expect about $1,300 in out-of-pocket costs given her health insurance; but, because she received out-of-network care and the hospital “misread” her insurance, it charged her $229,000.

    If you’re hospitalized and have commercial health insurance, including Medicare Advantage, you could be faced with higher out-of-pocket costs than you expected. You have little control over the doctors who see you and are at high risk of out-of-network doctors providing your care. They generally can’t charge above Medicare’s rate, but that can still be a lot. That said, depending on your income, you could qualify for charity care if you are in a non-profit hospital.

    Ms. French challenged her hospital charges in Colorado state court. Fortunately, the Colorado Supreme Court ruled in her favor. She was liable for only $766.74. It took eight years for her to get that decision.

    How did Ms. French end up with more than $200,000 in out-of-pocket costs? Centura Health, which runs the hospital that provided the surgery, billed her because her providers were out of network and her insurer would not cover their charges. And, Ms. French signed two agreements to pay all hospital charges after the hospital told her that her estimated out-of-pocket costs would be $1,300.

    Out-of-network rates can be ridiculously inflated: The out-of-network charges were the hospital’s full rates–the amounts listed on its “chargemaster.” The court ruled in Ms. French’s favor because she did not know there was a chargemaster and had never agreed to pay its rates. The hospital did not tell her anything about the chargemaster nor would it disclose the chargemaster during the litigation, claiming that the chargemaster was proprietary, a trade secret.

    Hospitals should not be able to charge any rate they please for out-of-network care: Chargemasters “have no basis in reality,” according to Gerard Anderson, a Johns Hopkins professor. They are not tied to the actual cost of a given treatment or procedure. Likely for this reason, hospitals tend to keep them confidential. President Trump ordered that hospitals make this information public, but they have never done so in a way that anyone can understand.

    Patients have no way to comparison shop for hospital care: Since patients have no clue what procedures providers will undertake, no control over them and little information about their costs, patients have no way to comparison shop for their care.

    What if you’re in a Medicare Advantage plan? As with insurance for working people, with Medicare Advantage plans, corporate health plans that cover Medicare benefits, your costs can be insanely high, especially if you’re in an HMO; in an HMO, if you see out-of-network providers, there is no limit on your out-of-pocket costs.

    Here’s more from Just Care:

  • United Healthcare cuts costs and jeopardizes access to specialty care.

    United Healthcare cuts costs and jeopardizes access to specialty care.

    Corporate health insurers have many ways to cut costs, including only contracting with network providers willing to accept extremely low rates and restricting the number of specialists in their networks. In an opinion piece for the South Carolina paper, the Post and Courier, Eveline Wang MD, an endocrinologist, explains how UnitedHealthcare slashed her practice’s provider rates well below Medicare’s. In short, UnitedHealthcare forced Dr. Wang and her colleagues to end their network provider contracts, allowing UnitedHealthcare to cut costs while jeopardizing access to specialty care for enrollees relying on these providers.

    Because of its leverage, Medicare is able to negotiate low rates with physicians, hospitals and other health care providers. Medicare’s rates tend to be significantly lower than corporate health insurance rates. UnitedHealthcare proposed to pay endocrinologists in Dr. Wang’s practice rates that were well below Medicare’s and well below their cost of delivering care.

    Dr. Wang treats people with complicated diseases, including diabetes. There’s a shortage of endocrinologists in the US. People wait long stretches to see an endocrinologist. Cutting endocrinologist rates in Dr. Wang’s area significantly below Medicare’s rates and effectively forcing these providers to end network contracts could mean leaving  many of their patients to die.

    What was UnitedHealthcare thinking and how is it allowed to set provider rates that are inappropriately low? Physicians cannot be expected to accept a payment rate below their costs. For sure, UnitedHealthcare saves money by slashing provider rates and by pushing physicians who see patients with complex conditions out of network. But, to protect patients, these insurer tactics should not be allowed.

    Here’s more from Just Care:

  • Health insurance prices are soaring

    Health insurance prices are soaring

    The national uproar over rising prices is justified. Every family on a budget — and that’s most of us — suffers when prices rise faster than wages for the basic necessities of life like food, fuel, housing and health … Whoops, I was about to write health care, but when I dug deep into yesterday’s inflation report, I discovered medical services prices rose just 3.5% over the past year, less than half the 8.3% rate for all goods and services.

    This is pretty much in line with the past decade’s trend in overall medical prices, which have gone up only 2.8% per year on average. That’s one reason why overall healthcare spending as a share of the economy remained relatively stable over the past ten years at around 17-18% of gross domestic product.

    That is, it was stable until COVID-19 came along. The massive government injection of cash into hospitals and physician offices, just as the economy was going into a tailspin, ballooned the sector’s share of GDP to 20%. In other words, health care spending remained steady while the rest of the economy tanked.

    However, the economy has recovered rapidly from the pandemic lockdowns. The latest government forecast projects health spending’s share of the economy will return to pre-pandemic levels by the end of this year, largely because prices in the sector have remained relatively tame while prices elsewhere skyrocket.

    So if prices for the delivery of health care remain under control, why are insurance prices, which presumably are based on the underlying cost of care, soaring? Last year, prices for health insurance rose a stunning 10.4%, which is even faster than inflation in the rest of the economy. While insurance prices are notoriously volatile and are even known to decline in some years (it’s known as the insurance cycle — don’t ask), prices for coverage have gone up on average 5.3% over the last decade or nearly twice the overall rate of health care inflation.

    How can that be? While the mainstream press has focused on hospital concentration as a major culprit behind rising health care costs, very little attention has been paid to insurance industry concentration.

    Just four publicly-traded insurance companies (UnitedHealth Group, Anthem, Aetna and Cigna) control 48% of the private health insurance insurance market. The top ten organizations (five of the next six are nominally non-profit) control 71% of the market.

    The American Medical Association’s 2021 survey of insurance industry concentration found 73% of the the nation’s 384 metropolitan areas are “highly concentrated,” according to federal guidelines. Just one insurer had over half the market in 46% of those regions.

    With access to medical services returning to normal, you’d think the profits for health insurers would be taking a hit. Not so. Samantha Liss at HealthCareDive this week reported insurer profits for the first quarter of this year saw every player posting sizeable gains over a year ago, including 21% higher for Centene and 13% higher for Molina (both highly dependent on Medicaid programs); 12% higher for Humana (highly dependent on Medicare Advantage); 8% for Anthem; 4% for CVS/Aetna; 3% for UnitedHealth, the nation’s largest insurer; and 2% for Cigna.

    Somewhat higher costs = much higher profits

    My former colleague Bob Herman, now at Stat, culled through annual proxy statements to report today that the CEOs at those seven firms raked in $283 million in salaries and bonuses last year. Herman points out that insurers, whose profits over the life of the insurance cycle are guaranteed since they recoup any short-term losses with higher rates in the succeeding year, have little interest in haggling for lower prices. The more health care providers charge, the more money insurers make since they eventually pass along their higher costs to their customers — the nation’s employers who purchase health insurance.

    “Employers in general are not well-served by the carriers,” Sabrina Corlette, a health insurance researcher and professor at Georgetown University told Herman. “The incentive structure is messed up. At a certain point, when is the employer community going to start storming state capitals and Congress with pitchforks?”

    If past is prologue, the answer to her question is never. One reason is that CEOs at many major companies are very familiar with the tactics being used by their compatriots in the insurance industry and have no interesting in calling them out. A new survey by the Groundwork Collaborative, a progressive think tank, shows that corporate CEOs and their finance officers admit on earnings calls that they are using war- and COVID-driven supply chain disruptions to hike prices over and beyond the actual increased costs they are experiencing.

    “Companies that historically might have kept prices low to pick up profit by gaining additional market share are instead using the cover of inflation to raise prices and increase profits,” Groundwork executive director Lindsay Owens wrote in this recent New York Times op-ed. “Consumers are now expecting higher prices at the checkout line, and companies are taking advantage. The poor and those on fixed incomes are hit the hardest.”

    Food, oil, household goods — the companies in the survey represented a broad cross section of the U.S. economy (although it didn’t include any insurers). Clearly, monopolistic pricing power is driving a significant share of today’s inflation.

    President Biden this week correctly noted that inflation has become America’s top “kitchen table” concern. But where’s the jawboning of America’s corporate leaders? He should take a page from one of his Democratic predecessors, John F. Kennedy, who in a 1962 press conference called out steel industry executives for price hikes that were “wholly unjustifiable and irresponsible defiance of the public interest” at a “serious hour in our nation’s history, when we are confronted with grave crises in Berlin and Southeast Asia, when we are devoting our energies to economy recovery and stability.”

    At this serious hour 60 years on, when the U.S. is backing Ukraine’s valiant fight against the kleptocratic-autocratic Putin regime in Moscow and Covid still poses a serious threat to our economy, is the current price gouging any less irresponsible or in any way justified? Clearly, our own kleptocrats are taking advantage of the current situation.

    Certainly, some of the recent short-term price spikes were inevitable given the war- and Covid-driven supply disruptions. But enough time has gone by for the economy to adjust, and it hasn’t.

    If Democrats facing tough election fights in the mid-term election are looking for an answer to voters’ chief economic frustration, they should point out repeatedly who’s behind ongoing and excessive price hikes — the leaders of America’s monopolized corporate sectors, our own version of the global kleptocratic class that is undermining peace and prosperity.

    This post was originally published in gooznews on Substack.

  • Warning: An air ambulance ride could cost $489,000

    Warning: An air ambulance ride could cost $489,000

    How much could you be charged if you take an air ambulance? For sure, many times what it actually costs. Julie Appleby reports for Kaiser Health News on a man who was charged $489,000 for his air ambulance ride. How do you protect yourself from such insane charges?

    Medicare and other health insurers should cover air ambulances when medically necessary. The question becomes what is medically necessary. Because they cost so much, it is in the corporate insurers’ financial interest to claim that air ambulance rides are not medically necessary.

    Appleby’s story profiles a 32-year old man, Sean Deines, who fell gravely ill while in rural Wyoming. He had a low white blood cell count, which turns out to be acute lymphoblastic leukemia. He needed emergency care, for which he was airlifted to the University of Colorado hospital. His insurer, Blue Cross Blue Shield of North Carolina, through his state health insurance exchange, covered that trip.

    After Deines is stabilized, he and his wife decided to get care at Duke University Medical Center, his in-network hospital in North Carolina, where his family resides. The air ambulance company they contacted, Angel MedFlight, said it would accept payment from his insurer, and he would have no responsibility for the cost.

    Notwithstanding representations from the air ambulance company to the contrary, Deines received a bill for $489,000, About $70,000 of the bill was for ground ambulance services in Denver and Raleigh-Durham. But, Deines’ insurer claimed this transport was medically unnecessary; he could have remained in Denver for 28 days of treatment to put his cancer in remission.

    The air ambulance company tried to get prior authorization from Deines’ Blue Cross plan, but it transported Deines before it had approval. After Blue Cross denied the service, Angel MedFlight appealed, which resulted in a check to Deines from Blue Cross for $72,000, covering a small portion of his services, which Deines forwarded to Angel MedFlight.

    Three months later, Blue Cross demanded its money back, saying it had paid the $72,000 in error. It ended up sending the debt to a collection agency. Angel MedFlight appealed again to an outside independent evaluator who ruled for Blue Cross, claiming that Deines could have stayed at the Colorado hospital.

    What can you do to protect yourself from an air ambulance and ground ambulance bill of this magnitude? Shop around. Recently, I helped a family member get from a hospital in Arkansas to a hospital in New York. The total charge for the air ambulance and the ground ambulances from and to the hospitals was under $20,000, a far cry from $489,000. It’s also a good idea to call your insurer to understand its coverage policy. But, it’s not likely you would know ahead of time whether the insurer would pay for the service or deny coverage on medical necessity grounds.

    NB: As of January 1, 2022, air ambulances must tell you the cost of their services ahead of time. The federal No Surprises Act should protect you from being charged anything more than what your insurance pays a network provider; it should also ensure you are told what your costs might be if your care is denied.

    Here’s more from Just Care:

  • Prior authorization: How dangerous is it?

    Prior authorization: How dangerous is it?

    Health insurers argue that requiring prior authorization before you receive certain services–approval for particular treatment–allows them to better manage your care. In fact, prior authorization requirements often lead health insurers to delay your receipt of care and can jeopardize your health. Traditional Medicare does not require prior authorization for medical services, but Medicare Advantage plans do, as do all commercial health insurers. What are the dangers of prior authorization?

    Prior authorization requirements give health insurers the ability to come between you and your treating physician to decide whether the care your doctor recommends is medically reasonable and necessary. Too often, health insurers take their pretty time in deciding whether they will cover the care treating physicians recommend. And, if it’s a specialty procedure, the person deciding often has no specialty expertise. That health insurer employee might even have a financial incentive to delay or deny your care.

    Lola Butcher reports for Medscape on one oncologist who believes prior authorization requirements resulted in the death of his patient. In that case, the health insurer refused to approve a PET scan when the oncologist initially sought authorization for it. The insurer came between this physician and his patient, delaying the patient’s care and allowing more time for the patient’s cancer to spread.

    The oncologist fought the health insurer’s denial of the PET scan, insisting that it was standard care for a patient in his condition. During the more than three weeks it took the doctor to get the insurer to approve the procedure, the patient was hospitalized because his symptoms grew worse.

    Unfortunately, inappropriate denials resulting from prior authorization are not uncommon. Inappropriate delays of three to four weeks or more while physicians argue with the health insurer, are also not uncommon. And, physicians say that insurers are using prior authorization requirements for medical procedures and prescription drugs more often.

    There are two sides to the prior authorization story. Prior authorization could keep doctors who are not following standard protocols from providing improper treatments. But, do they do more harm than good?

    To complicate matters, there’s no way to know what medical protocols health insurers are following when they deny coverage for a procedure. Unlike other countries that set the medical protocols for private health insurers, our government allows insurers’ medical protocols to be proprietary. Yet, these protocols can result in people not getting needed care in a timely manner. Health insurers have a financial incentive to delay and deny care inappropriately as the less money they spend on care the more they profit.

    One doctor reports that he tried to prescribe a patient who had an infection the standard drug for the standard 10-14-day course of treatment. But, the insurer would only authorize the drug for five days, even though there is no data to suggest five days is adequate.

    Another doctor reports that a patient of his needed an ultrasound and MRI twice a year to monitor her for breast cancer, as she was at high risk, testing positive for the BRCA gene and with a family history. But, the insurer has required him to get prior authorization each time his patient needs the procedures. This takes up a lot of his time for no legitimate reason. Her medical history is not changing.

    The stories of inappropriate delays caused by prior authorization requirements are seemingly endless. And, they happen even when patients are in emergency situations. It’s not every health insurer, but reports suggest that it’s a significant proportion of them. People have no clue which health insurers to avoid.

    Sometimes insurers require patients to get particular tests before they can get a procedure. The problem is that a negative test result might not indicate that the patient does not need the procedure. One specialist explains that the MSLT is often wrong as a measure for whether a patient suffers from narcolepsy. But, some insurers require it in place of the treating physicians’ expert opinion, undermining their patients’ care.

    Appealing wrongful insurance company denials also can be extremely time-consuming.

    Some states are finally intervening. Texas, for example, does not permit health insurers to require physicians to seek prior authorization if the physicians have met the insurers’ medical necessity criteria at least 90 percent of the time in the past six months. In Illinois, a new law limits the number of services for which insurers can require prior authorization and mandates that insurers make a determination within five days.

    The US Congress is also considering bi-partisan legislation to protect people from some of the burdens of prior authorization. It focuses on limiting the use of prior authorization by Medicare Advantage plans and requiring Medicare Advantage plans to make real-time coverage decisions in certain cases, as well as to have an electronic prior authorization process.

    Here’s more from Just Care:

  • The myths health insurers want you to believe

    The myths health insurers want you to believe

    When I was a health insurance communications exec, I was a big part of an ongoing effort–funded by your premium dollars–to get you to believe big myths about the U.S. healthcare system.

    Even a minute or two of Googling would have disproved our claims, but we succeeded because we knew most people wouldn’t bother. For the most part, health reform advocates have also not been up to the task of challenging the misinformation and setting the record straight.

    Why do my former colleagues keep this deception going? For a single reason: to protect what has become an extraordinarily profitable status for health insurers. As long as you (and the people you vote for) keep believing the myths, you will be parting with far more of your hard-earned dollars than you should to keep insurers’ shareholders happy.

    Let’s look at three of those myths.

    Myth 1: The U.S. has the best health care system in the world. 

    While there is no doubt we have some of the very best hospitals, technology, physicians and other caregivers, we are nowhere close to having the best system. My former colleagues and I perpetuated that myth because we wanted you to think that any kind of significant reform is unnecessary, especially if the reform might reduce insurance revenues and profits. We didn’t even want you to think that the millions of Americans without insurance is a big deal because, well, those are just people shirking their individual responsibility by remaining uninsured. In other words, it is their fault, not the system.

    In 2004, long before the Affordable Care Act was passed, the Commonwealth Fund launched a major project to assess the performance and fairness of several developed countries’ health systems. Of the 11 systems assessed, ours came in dead last. They have updated the assessments every couple of years, and the top-performing systems have varied over time, but one thing has remained constant: the U.S. continues to bring up the rear–despite the ACA.

    The Commonwealth Fund’s most recent assessment, published just this month, found that once again, the United States “trails far behind” other high-income countries on measures of health care affordability, access, administrative efficiency, equity, and outcomes. This is despite the fact that we spend far, far more of our GDP on health care than any other country on the planet.

    So yes, we do indeed have some of the world’s best health care providers, but they are off limits to millions of us, because of the fragmented nature of how we pay for care and the administrative burden and costs associated with world-leading inefficiencies on the payer side.

    Myth 2: Our employer-based system of health coverage works beautifully, and we can count on it to be there when we need it. 

    That myth was busted big time last year when we witnessed millions of Americans losing their coverage along with their jobs during the pandemic. The truth is that most people who have employer-sponsored insurance (ESI) are just a layoff or plant closing away from being plunged into the ranks of the uninsured.

    The insurance industry and its allies, including the U.S. Chamber of Commerce, which just published a commentary on its website extolling the virtues of ESI, have persuaded politicians on both sides of the aisle to remind us that more than 150 million Americans get their coverage through the workplace. What they don’t tell us is that that number hasn’t increased much at all over the past 20 years while the U.S. population has grown by more than 50 million.

    One big reason: fewer than a third of small U.S. businesses now offer coverage to their workers, compared to around half two decades ago. The average family policy through an employer has increased to more than $21,000 a year, according to the Kaiser Family Foundation, and the cost of insurance has gotten so high that more and more small employers are throwing in the towel.

    Even our biggest employers are now realizing that the cost of providing coverage to their workers is out of control. An astonishing 87% of the top executives of America’s largest companies say the cost of providing health insurance will become unsustainable for them in the next five to ten years, according to a survey conducted earlier this year by the Kaiser Family Foundation and the Purchaser Business Group on Health.

    Myth 3: Health insurers are appropriate and efficient gatekeepers to healthcare.

    Under the pretense of reducing unnecessary and inappropriate care, insurers began making providers get approval from them in advance before treating people enrolled in their health plans. But by putting increasingly aggressive prior authorization requirements in place, these policies also reduce access to care that is both necessary and appropriate, and insurers avoid paying an untold number of claims.

    Insurers have become so aggressive that one in four doctors say prior authorizations requirements have caused “serious adverse events” for their patients and in more than a few instances have contributed to premature patient deaths (according to the American Medical Association).

    Insurers have succeeded in persuading employers and policymakers that these prior authorization requirements save money, but there is little evidence to support that. In fact, prior authorization demands add considerably to the high administrative expenses the Commonwealth Fund and other researchers note are unique to the U.S. healthcare system.

    Ultimately, these myths serve to preserve the status quo. Insurers continue to bring in record profits, by making care harder to access. Perpetuating these myths are central to deflecting criticism and avoiding reform.

    This post was originally published on Un-covered.

    Here’s more from Just Care:

  • Confirmed: Private insurance is full of ugly surprises

    Confirmed: Private insurance is full of ugly surprises

    Thank god that Medicare regulates provider rates for older and disabled Americans and gives people a meaningful choice of public insurance–traditional Medicare–that covers virtually all medically reasonable and necessary care from the doctors and hospitals you want to use. Private health insurers have tremendous freedom to decide when care is needed and what you’ll pay and no obligation to disclose their policies. That’s why private health insurance is usually full of ugly surprises.

    Sarah Kliff reports for the New York Times on the highly varying prices hospitals charge health insurers for the same service. Kliff’s story underscores two huge issues with health care coverage in the US for working people: People cannot choose a corporate health plan that’s right for them, since they cannot predict their out-of-pocket costs. The high and highly varying rates that health insurers negotiate with providers presumably benefit them, but add no value for their members.

    Kliff’s piece, which examines the different prices different insurers pay for different services reveals once again that, in many cases, corporate health insurers are either unwilling or unable to rein in provider rates. She shows that, for example, at the University of Mississippi Medical Center, people without insurance pay $782 for a colonoscopy, about 35 percent of what someone with coverage through Aetna pays, $2,144, and almost 50 percent of what someone with coverage through Cigna pays, $1,463.

    Kliff is only able to report this story now because the Trump administration mandated the disclosure of hospital negotiated provider rates. Many hospitals are not yet complying with the requirement or are burying the information so that it is extremely difficult to find. The Biden administration is threatening to penalize hospitals who are not open and transparent about their rates.

    Kliff also uncovers that some people in PPOs pay higher rates for the same services than their counterparts in HMOs offered by the same insurer. The same insurer offering a PPO and an HMO product might negotiate far higher rates for the same services offered through the PPO than through the HMO. Why would that be?

    People living in different states, with the same insurer, receiving the same service at the same hospital also might pay wildly different rates. At the Hospital at the University of Pennsylvania, a pregnancy test for New Jersey patients in the Blue Cross PPO  is $93, while the test is $58 for New Jersey patients in the Blue Cross HMO. For the same test, patients who live in Pennsylvania pay $18. And, the hospital charges uninsured patients $10.

    People with United Healthcare’s PPO pay $4,029 for an MRI at Aurora St. Luke’s in Milwaukee. People with United Healthcare’s HMO pay $1,093 for the same service. This craziness hurts patients and prevents them from being able to protect themselves financially.

    If this story tells us anything is that the health care market is broken. Congress must step in to protect Americans from a totally irrational health care pricing system. The simplest way to do so is to do what every other country does, all-payer rate-setting–setting rates for all providers.

    Here’s more from Just Care: