How Bad is our Health Insurance System?

For-profit Insurance companies have no business providing healthcare for government beneficiaries!??????????? By Kerry Goff

Unless you have been living under a rock, you have been following the ongoing sad saga of United Healthcare and the murder of its healthcare division CEO, Brian Thompson, an Iowa farm boy, loving father and husband.

To this day, we are not even sure that Mr. Thompson was murdered because of alleged excessive denial of claims, although social media has already tried and found him guilty.

?As a hospital CEO and consultant, I can confirm that all hospitals and most patients are fighting an on-going battle against various for-profit insurance companies who deploy deny, delay and depose in their tactics. The glaring problem with deny, delay, depose is when for-profit insurance companies provide “care” for seniors by way of Medicare Advantage.

There are so many contributing factors to the problem of providing healthcare for seniors. It is not so much one insurance company, but the unintended consequences brought about by CMS, when, in their desperation to save money, did all they could to remove themselves from the financial responsibility of insuring the most prolific users of healthcare during their sickest times—abdicating their responsibility in favor of enriching insurance company stockholders.

I did some Chat GPT research to remind me of the order in which things happened. I did not write this article with Chat GPT, only used it for a few pieces of source material.

This mess started back in the early 1980s with the Tax Equity and Fiscal Responsibility Act (TEFRA) which allowed Medicare Beneficiaries to buy their own HMO based medical care instead of taking basic Medicare. Always looking for ways to save money, CMS began looking at shifting the responsibility from themselves to insurance companies.

In 1997 CMS (at that time HCFA) established Medicare+Choice. This was back when everyone thought HMOs were going to save healthcare. CMS’s goal was to move every Medicare beneficiary to one of these plans. Well, as you can imagine insuring older people became expensive. So, in true government fashion they gave these “for profit” insurance companies more money. Around 2003, in an effort to improve the bad reputation that Medicare+Choice had developed, CMS changed the name of Medicare+Choice to Medicare Advantage. It worked and today nearly half of all Medicare beneficiaries are covered under a Medicare Advantage plan.

As time has progressed, it has become more difficult for the participating insurance companies to operate in ways that satisfy stockholders. So, most did what any good insurance company would do, they combined increased premiums with denials and delays of coverage. This is the real problem with for-profit insurance companies making healthcare decisions for covered beneficiaries. The profit motive far outweighs the care motive!

I do not see this situation ever changing. It will take political action. However, insurance companies are too rich and have their hands deep in the pockets of the politicians who would be required to drastically improve this perverted process. It would take many good people in Congress to make these changes. And, as you know there just aren’t that many of those around who are willing to fight the insurance companies and their lobbyists. I have also found, as I am sure you have, that in Washington, there is a great deal of ignorance regarding almost any insurance, but specifically Medicare Advantage Plans. ?

Much more needs to be done. But in the interim, you can do something on your own. If you, or anyone you know are eligible for Medicare, instead of Medicare Advantage, look in to keeping regular Medicare with a Medicare Supplement or “gap plan.” These plans while usually offered by the same insurance companies have a more consumer friendly plan design and claims process, and basically pay what is not paid by Medicare. The caveat is that they require a premium and payment for a drug plan, while Medicare Advantage plans are often free and provide a free drug plan.

Many seniors get stuck buying a Medicare Advantage Plan because there is no up-front premium. However, it will cost later in copays, deductibles and denied claims.

This problem needs to be solved, but it will take a concerted commitment by all parties. ?In the meantime, let’s stop blaming individuals and look at the broader picture and hold the companies responsible. Don’t let them fix it themselves. They need oversight. We must protect our parents and grandparents from these plans. And it needs to happen sooner than later. ?