The Real Culprits: How Politicians Are Responsible for the Decline in Health Insurance Coverage
Introduction
While many people blame health insurance companies for the increasing number of claims denials and barriers to care, the true culprits are lying politicians. The Affordable Care Act (ACA) regulations have significantly contributed to the rise in claim denials, with the percentage increasing from 1.5% to nearly 15% since the ACA rules came into effect. Additionally, insurers now require preauthorizations for various treatments and medications, leading to delays in care.
The Impact of Insurer Demands
Your doctor now has to contact the insurer before beginning treatment or prescribing medication, often speaking to someone who lacks expertise in the specific disease or treatment. For example, an OB-GYN may override a recommendation from a neurosurgeon. This situation can have dire consequences, as demonstrated by Dr. Debra Patt’s case, where she had to settle for standard chemotherapy due to the lengthy prior authorization process, resulting in the death of her patient.
The Problem with Health Plan Representatives
Health plan representatives, who may have no medical background, are now making treatment decisions without ever meeting the patient or being present at the bedside. This lack of medical expertise can lead to questionable decisions and hinder the provision of appropriate care.
Overturned Denials and Algorithm Use
Testimony from the House Committee on Energy and Commerce revealed that 80% of the preapprovals denied by Cigna for Medicare Advantage customers were overturned on appeal, indicating that legitimate care is being withheld. Cigna utilizes an algorithm called PxDx to mass deny prior authorizations. These denials and prior authorization requirements have escalated since the implementation of the ACA.
The Role of Profit Maximization
The blame for the unreliability of health insurance should not be solely placed on profit maximization. The ACA regulates underwriting profits, and insurers are required to provide rebates to customers if profits increase. Instead, large insurance companies like United Healthcare have grown by acquiring physicians’ practices, hospitals, and pharmacy chains.
The Broken Promise
The unreliable nature of health insurance can be traced back to politicians who backed Obamacare and made an impossible promise. They claimed that everyone would be charged the same regardless of their preexisting conditions. However, this promise ignores the fact that 5% of the population accounts for over 50% of healthcare usage each year.
The Need for Extra Payments
The federal government should have stepped in and provided extra payments to cover individuals with preexisting conditions. Instead, insurers were inundated with new claims and forced to resort to cost-cutting measures, resulting in delays in treatment and claim denials.
The Winners and Losers
Democratic politicians emerged as winners, as covering preexisting conditions at no additional cost gained popularity. However, the losers in this situation are everyone else who now faces concerns about delayed treatments and denied claims. The most affected are the seriously ill, who suffer disproportionately from managed care’s strict controls.
Push for Change
More than half of states have started passing laws to limit prior authorization, which is a positive step. However, it is crucial for Americans to reassess managed care, as there is minimal evidence that it improves health. Despite claims by President Joe Biden’s assistant secretary of health policy that the ACA’s coverage expansion reduced morbidity and mortality, statistics show that Americans are sicker and living shorter lives than before the ACA.
Consider Catastrophic Coverage
One alternative to explore is low-cost catastrophic insurance, which would only cover significant medical expenses. This type of coverage would benefit healthy individuals who receive coverage through their workplaces, resulting in fewer interactions with insurers and increased take-home pay. Democrats often label catastrophic coverage as “junk insurance,” but many Americans are starting to realize that health plans that deny claims and delay preauthorizations are the real “junk.”
Disclaimer: The opinions and views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the news outlet.
