REUTERS
Everyone’s blaming health insurance-company greed for soaring costs, rising claims denials and daunting roadblocks to care.
That’s naïve.
Follow the money to find the real culprits: lying politicians.
In 2013, before Affordable Care Act regulations kicked in, insurers denied roughly 1.5% of claims, according to the American Medical Association.
But under ACA rules, denials increased tenfold.
Now nearly 15% of claims are denied, reports Premier, an insurance consultant firm.
Some insurers deny a third or more of claims, according to Kaiser Family Foundation research.
Insurers are also increasingly demanding pre-authorizations for a wide range of treatments and medications, tying your doctor’s hands and in some cases dangerously delaying care.
Your doctor has to call the insurer before beginning treatment or ordering a medication — and seldom is the person on the other end of the phone a specialist in the disease or treatment in question.
It could be an ob/gyn overriding your neurosurgeon’s recommendation, warns the AMA.
Dr. Debra Patt, an oncologist in Austin, Texas, told the AMA she prescribed a drug combination for a patient with metastatic breast cancer, but had to wait weeks for pre-authorization.
In the meantime, she had to settle for ordinary chemotherapy, a substandard treatment for the case.
Her patient died.
“You have health plan representatives who have never met the patient, have never been at the bedside or practiced medicine, but are now making treatment decisions,” objects Tina Grant of Trinity Health, a nationwide chain of 27 Catholic hospitals.
Moreover, according to House Committee on Energy and Commerce testimony, 80% of preapprovals that Cigna denied for Medicare Advantage customers were overturned on appeal — a sign that legitimate care is being withheld.
Cigna uses an algorithm called PXDX to deny prior authorizations in bulk.
Denials and prior authorization requirements escalated after the ACA went into effect.
But don’t blame the profit motive: The law regulates and limits profits on health policies.
Underwriting profits are measured by the “medical loss ratio,” the portion of premium revenue spent on health care.
(The industry considers that spending a “loss.”)
The ACA requires individual and small-group plans to spend 80% on care, and large plans to spend 85%.
An insurer that fails to do so, and profits too much, has to send a rebate to its policy holders.
Giants like United Healthcare have grown into money-making behemoths not by selling health plans, but by buying physicians’ practices, hospitals and pharmacy chains, IBIS industry research found.
The actual reason for your health insurance’s increasing unreliability is this: The politicians who backed Obamacare knowingly made a promise that was impossible to keep without insurers resorting to predatory practices.
Obamacare advocates promised everyone would be charged the same, regardless of their “pre-existing conditions.”
But the math doesn’t work: Every year, just 5% of the population accounts for more than 50% of our health-care spending.
That’s a fact of nature, politics aside.
Telling insurers to cover the unhealthy 5% for the same premiums charged to healthy people is like trying to spend the same on monthly groceries for a skinny fashion model and a Nathan’s hot-dog-eating champion.
Ridiculous.
The federal government could have stepped in with extra financial assistance to cover people with pre-existing conditions.
Instead, insurers were hit with a mountain of new claims and told to make it work.
They did — by adopting draconian cost-cutting methods.
The winners?
Democratic politicians.
Covering pre-existing conditions at no extra apparent charge is popular.
The losers?
Everyone else, who now has to worry that their next treatment will be delayed or their next claim denied.
The biggest losers, sadly, are the seriously ill — who suffer disproportionately from managed care’s tight controls, according to the National Bureau of Economic Research.
Many states are now passing laws to limit prior authorization.
That’s a step in the right direction.
But Americans need to reassess managed care: There is next to no evidence it improves health.
President Biden’s Department of Health and Human Services has boasted that the ACA’s coverage expansion — mostly in managed care — reduced “morbidity and mortality.”
That’s a blatant lie.
Americans are sicker and living shorter lives today than before the ACA went into effect.
One alternative: Allow low-cost catastrophic insurance, which kicks in only for the largest medical bills.
Healthy people who get coverage at work could pay for routine care on an out-of-pocket basis.
They would benefit from fewer interactions with an insurer and more take-home pay in lieu of a whopping $25,000 plan — the average cost this year for family coverage.
Democrats try to label catastrophic coverage as “junk insurance.”
The Biden administration has made it almost impossible to buy.
But as Americans are beginning to see, health plans that turn down legitimate claims and require dangerously long waits for preauthorization are the real “junk.”
Betsy McCaughey is a former lieutenant governor of New York and co-founder of the Committee to Save Our City.