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Everyone blames health insurance greed for the increasing denial of requests and roadblocks. That’s naive. Follow the money to find the real culprits: lying politicians.
In 2013, before the Affordable Care Act regulations took effect, insurers denied roughly 1.5% of claims, according to the American Medical Association. But under the ACA rules, denials increased tenfold. Now almost 15% of claims are rejected, reports Premier, an insurance consultancy. Some insurers deny a third or more of claims, according to research by the Kaiser Family Foundation.
Insurers also require pre-approval for a wide range of treatments and medications, tying your doctor’s hands and dangerously delaying your care.
THE YEAR IN CANCER: PROGRESS MADE IN 2024, FORECASTS FOR 2025.
Your doctor must call the insurer before starting treatment or ordering medication. Rarely is the person on the other end of the phone an expert in the disease or treatment in question. It could be that the gynecological exam goes beyond what your neurosurgeon recommends, warns the AMA.
Anger against health insurance companies is misplaced. People should hold politicians accountable for the problems they have caused. (iStock)
dr. Debra Patt prescribed a combination of drugs for a patient with metastatic breast cancer, but had to wait weeks for pre-approval. Meanwhile, the AMA reports, she had to settle for standard chemotherapy, but to no avail: her patient died.
“You have health plan representatives who have never met a patient, never been at a bedside or practiced medicine, but now they’re making treatment decisions,” argues Tina Grant, senior vice president of public policy and advocacy at Trinity Health, a 92-hospital Catholic hospital system.
According to House Committee on Energy and Commerce testimony, 80% of pre-authorizations denied by Cigna for Medicare Advantage beneficiaries were overturned on appeal, a sign that legitimate care was being denied. Cigna uses an algorithm called PxDx to massively deny prior authorizations.
Denials and pre-authorization requirements escalated after the ACA went into effect. But don’t blame it on profit maximization. The ACA regulates underwriting profits, and if profits rise, insurers must send rebates to customers.
Giants like United Healthcare have grown into giants that make their money by buying doctors’ offices, hospitals and pharmacy chains rather than selling health plans, according to industry research IBISWorld.
The real reason why your health insurance becomes unreliable is that politicians who support Obamacare knowingly made a promise that was impossible to keep without insurers resorting to predatory practices.
Obamacare advocates promised that everyone would be charged the same regardless of their “pre-existing conditions.”
The math doesn’t work. Every year, 5% of the population uses more than 50% of health care. It is a natural fact, politics aside.
Politicians, like President Barack Obama, pushed Obamacare knowing it would be difficult for insurance companies. FILE: Obama celebrates after accepting his party’s nomination during the Democratic National Convention in Charlotte, North Carolina, Thursday, Sept. 6, 2012. (Photo by Christopher Evans/MediaNews Group/Boston Herald via Getty Images)
Telling insurers to cover 5% for the same price they charge healthy people is like giving a month’s worth of groceries to a skinny model and the winner of a Nathan’s hot dog eating contest for the same price. Funny.
Five percent more premium payers and 50% more medical needs.
The federal government should have stepped in with additional payments to cover people with pre-existing conditions. Instead, insurers were given a mountain of new claims and told to make it work. They adopted draconian cost-cutting methods.
The winners? Democratic politicians. Covering pre-existing conditions at no additional cost is popular.
Losers? Everyone else who has to worry that their next treatment will be delayed or their next application will be refused.
The biggest losers, unfortunately, are the seriously ill, who suffer disproportionately from tight controls on managed care, according to a National Bureau of Economic Research article on Medicaid managed care.
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More than half of the states now pass laws limiting prior approval.
It is a step in the right direction. But Americans need to reevaluate managed care.
Denials and pre-authorization requirements escalated after the ACA went into effect. But don’t blame it on profit maximization. The ACA regulates underwriting profits, and if profits rise, insurers must send rebates to customers.
There is almost no evidence that it improves health.
President Joe Biden’s assistant secretary for health policy boasts that the ACA’s coverage expansion — mostly in managed care — has reduced “morbidity and mortality.” That’s an outright lie. Americans are sicker and living shorter lives than before the ACA.
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One alternative is to allow low-cost catastrophe insurance, which applies only to large accounts. Healthy people who get insurance at work would benefit from fewer interactions with the insurer and a bigger take-home pay instead of the plan’s staggering $25,000 — this year’s cost of family insurance.
Democrats are trying to label catastrophic coverage as “junk insurance.” The Biden administration has made it nearly impossible to buy. But Americans are starting to see that health plans that deny claims and make you wait dangerously long for pre-authorization are real “junk.”
