We Don't Need a Different Healthcare Middleman
What if we got rid of health insurance companies and instead made employers the payers? Well, that still wouldn't be a universal system. We need Medicare for All.
Image: Wikimedia Commons.
I always find it interesting when doctors opine on healthcare in the United States. I find it even more interesting when doctors opine on healthcare and specifically fail to mention Medicare for All, a single-payer universal system which would cover everyone at no cost at the point of service. And I find this even more interesting because Medicare for All is popular: a YouGov poll from July 7 shows 59 percent of respondents favoring the policy. Free care sounds pretty great to me. Right now, I am uninsured as I wait for my ACA plan to kick in after I experienced a “qualifying event” and had to get a new one. Healthcare costs are a massive burden on Americans and are a leading cause of bankruptcy. Medicare for All would end all this financial toxicity once and for all.
When I saw a Meidas Health podcast show up on my feed, I knew I was going to have to take a listen. (I had not heard good things about Meidas Touch.)
Image: Screen shot of Meidas Health podcast page.
The episode featured two doctors, one of whom is Dr. Elisabeth Potter, a reconstructive plastic surgeon who has gone viral online for her videos of “peer-to-peer” calls with insurance companies that are eager to deny her patients the care they need. Earlier this year, United Health went after her because of her advocacy, threatening her with legal action. As far as doctors go, she’s in the trenches of patient care and operates her own breast surgery center. So, before I get into a discussion of her views on healthcare as featured on the podcast, I want to acknowledge her hard work in taking care of and advocating for patients, including many patients who aren’t able to be seen in other surgery centers and have to travel long distances to get to her. (Surgeons go through some of the most grueling training of any specialty, and their skills are something I have a lot of respect for.) And through her online videos, Potter is educating the public about just how antagonistic health insurance companies are toward actually providing care to people. So, she’s doing valuable public service on multiple levels.
What concerned me about the episode, though, was the lack of mention of Medicare for All. Part of this may have had to do with the subject of the episode, which was specifically about claims and claim denials (both guests deal with claims issues in their work). So, the guests talked about how they have been dealing with these denials of care. That’s all fine. But here’s my first point: I sometimes fear that all this talk of claims and illegitimate peer-to-peer calls with unqualified personnel will lead to the idea that maybe we just need better peer to peer. Maybe we just need to tweak the claims process!
The American Medical Association has advocated for exactly this, pointing out that peer-to-peer calls need to be handled by people in the same specialty as the prescribing doctor. Fair enough—no argument from me against that. But that’s not really the root of the problem here and would only address one tiny part of the health insurance bureaucracy problem. And this is coming from the AMA, which has always been against single-payer healthcare! So, tweaks like this are fine, but we need to keep our eye on the prize: coverage for everyone with Medicare for All.
The other thing that’s weird about nobody on the podcast ever mentioning Medicare for All is that they say multiple times that claim denials are an “every person problem.” (The other guest, Dr. Warris Bokhari, says he grew up in England yet never mentions the NHS! ) Hmm. Every person, you say? What if there were a proposal that would cover every person? There is! It’s Medicare for All. But they never talk about it.
As the episode progresses, it’s made clear why they don’t mention Medicare for All. Potter says that “markets” can improve the situation faster and better than “government.” Right there that tells me that she is not gonna be into a universal single-government-payer system. What a bummer. (Also: I don’t know about you, but when I hear “markets making change” and “government” together in the same sentence, frankly, I think about market bubbles bursting and the government bailing these industries out. That’s what I think of. But anyway!)
At one point the host says that policy discussions around who is covered and who isn’t are not as compelling as personal storytelling (of the kind that the two doctors on the show are doing). That’s another way of saying he’s not interested in discussing a universal system. Another bummer.
Then the host does a weird thing. After just having said that claim denials are an “every person problem,” he makes it clear who this podcast is really for: people with “likely good insurance.” He says that people who have fairly good insurance cannot relate to these discussions of who is covered and who isn’t. Okay, I guess he’s eliminating from his audience the 26 million Americans who lack insurance now. I guess these people are not “every people” enough to merit consideration in this discussion because they aren’t privileged enough to experience claim denials?!
What a cluster.
Anyway, moving on. There are some other interesting points in the discussion that came up that I’d like to answer directly. Potter admits that insurance companies aren’t interested in delivering care to patients. Ok, so then why does she think they are reformable to do better via the “market”? This just doesn’t make sense to me. We’ve all seen how far these companies will go to silence criticism. How can any of us still think that they are capable of being reformed?
Her idea of making companies do “better” comes from this idea she expresses about “good actors and bad actors” in the system. She says she’s a good actor. She tried to participate in the system and see patients through traditional insurance networks. But when that didn’t work, then she started her own breast surgery center to see patients outside of traditional networks. This is fine, but is it really a solution? Should every doctor taking care of patients have to turn into an entrepreneur who drains their bank accounts in order to work against “the system”? Why should anyone do heroics when we can just get rid of the system entirely?
The problem here is thinking of “bad apple” insurance companies as the problem. That’s not the problem. The rot is much deeper. Like with the cops, it’s not about a few bad ones—it’s systemic. IT’S ABOUT THE ENTIRE PROFIT MOTIVE IN HEALTHCARE.
Potter’s idea is that the market can discipline health insurance companies into doing better. She suggests, for instance, that when open enrollment comes around, employers should not contract with the “bad actors” and instead choose the good ones. Ok. But what makes a health insurance company good? Merely a lower claim denial rate? Better copays? Better peer to peers? I mean this is pulling teeth. What is actually the ultimate goal here? Something merely less bad but with the profit motive still intact?
At one point, the host says that even if you have “Cadillac, gold-plated” insurance, a claim denial can happen to you. That’s a profound statement. If you can have the best insurance and still not get the care you need, it sounds like that insurance ain’t all that useful. Potter herself ultimately admits that health insurance is not a useful institution. Instead, she argues, what would be good is for doctors to contract directly with employers. So, instead of employers contracting with an insurance company to cover their employees with a plan, they could contract directly with doctor networks.
Now, there’s a part of this I like and a part I absolutely hate. The part I like is the implication that health insurance needs to go. That’s great. But the part I hate is the idea that we simply need a new middleman…. the boss. Is she for real? Workplaces are way too antidemocratic (union density is super low in this country) for me to even think that employers are going to be good healthcare payers here. What about for-profit companies that pay for their employees’ plans? What’s to stop them from doing the same shit the health insurance companies do now for the sake of their bottom line? And Americans change jobs so often that tying healthcare to their employer just doesn’t make sense.
And, of course, what about the Americans whose employers fail to offer insurance at all? What about them? They’re totally left out.
What this idea really does is create a bunch of single-payer-ish fiefdoms, which seems silly. I say single-payer-ish because this kind of system really is not equivalent to a universal single-payer system in that you aren’t going to get the large-scale cost savings benefits. If you want to go directly from payer to provider without a profit-hungry middleman—and you want to give the payer the bargaining power of scale to negotiate, say, drug prices—let’s use the democratic institution we already have in place: our government.1
Potter herself admits that insurance companies have a fiduciary responsibility to their shareholders to maximize profit. Damn right they do! That is what needs to go. Along with tying healthcare to employers!
So, like I said: eye on the prize. Medicare for All. (And Medicare for All that includes people without citizenship as well as prisoners.)2
Yes. The government is corrupt. I’m aware that our government is fucked up. I’m saying we have to keep fighting to reclaim it so that it can act in the public good. Universal government programs like Social Security and Medicare are popular and reliably pay out benefits all the time. There’s no reason we cannot also do Medicare for All!
I’d love to see a debate between Potter and someone like Adam Gaffney MD, MPH or Abdul El-Sayed, MD. They’re both physicians and well versed on Medicare for All.