Most people who have any significant experience with the American healthcare system understand just how broken it is for all but the healthiest (or wealthiest) of people. The main problems stem from the medical insurance system and other financial matters, but also include access to timely, quality non-emergency care, fragmented medical records, and the lack of emphasis on preventative care. Much has been written about all of these topics and many other issues that plague the industry, and based on that and my own experience I can see one common root cause: the valuing of profit over the basic principles human decency. As a society we’ve accepted the reality of profit morality in business, but surely an industry that exists to heal and care for people should feel a different set of motivations. Our lives depend on it.
Before I go on, I want to be clear that I deeply respect and appreciate all direct care providers who have the well being of their patients at heart and their efforts to support it. I believe that the majority of providers fall into this category and are successful at providing good care to their patients, but systemic issues hinder their efforts at many points along the way. And it’s important to realize that healthcare workers are also harmed by our profit-first system. When they are put into a situation where the system doesn’t provide enough to meet a patient’s medical needs, their compassion compels them to put in unreasonable amounts of effort to bridge that gap. These efforts are what keep the system from completely collapsing, and companies take advantage of human compassion to squeeze as much as they can out of as few workers as possible. While the additional energy these people put in is honorable and critical to ensuring our health, it is also what allows these harmful practices to continue. This is just one of the ways that the problems are so deeply ingrained that they affect treatment decisions and can limit access to the best options.
Reliance on the health insurance system is one of the major causes of limited access to healthcare. The vast majority of people can’t afford the exorbitant costs associated with medical care and are therefore forced to rely on third party payers like insurance companies and sometimes government programs. In this way, insurance companies (and government programs, which I’m including when I say “insurance companies” for the sake of brevity) are the gatekeepers to who gets what kind of (if any) care. The problem with this is that insurance companies above all want to reduce their expenses, and that gives them a strong incentive to cover as little as possible. One of the statistics that’s used when discussing access to healthcare is the percentage of people with health insurance, but this figure is meaningless without considering whether the insured are getting the care they need without having to fight for it or pay excessive premiums, co-pays, and deductibles. This article provides some insight about high deductibles. Simply having insurance doesn’t mean you will have all your medical needs met.
We don’t hear much about the impact of insurance denials and gaps in coverage on the individual patient. I don’t think it’s possible to quantify this because the practice of allowing insurance companies to dictate our medical decisions is so institutionalized. Doctors routinely have to alter their prescriptions and treatments based on what a particular insurance plan covers, and sometimes there are no viable alternatives. Then the additional burden of appealing to have an exception made or to prove that a specific treatment ordered by a licensed physician is in fact medically necessary largely falls on the patient, who is already sick or suffering from some ailment. This process also requires the doctor to spend time writing justifications, which could be spent on patient care.
A system where people pay expensive premiums and then have beg to receive partial coverage for essential medical treatments when they need them the most is nothing less than fraud. Various policies and terms make these practices seem justifiable and are strengthened by decades of precedent, but they are all just ways for insurers to shirk their responsibility to their clients. Taking advantage of the sick and injured and placing obstacles in the way of their recovery is cruel and unusual punishment for the crime of just needing help. We cannot continue to sugar-coat and double-speak these practices to justify profits for a handful of companies to profit at our expense. The solution is simple — make health insurers actually provide the services they are meant to, without hiding in legalese and policies that limit the care that patients receive.
Suggesting that a problem of this proportion has a simple solution may be naive, but stay with me for a moment. As long as insurance companies have a say in medical decisions, they are taking on the role of a doctor. Just as doctors are investigated, punished, or sued for malpractice, if insurance companies deny or delay a treatment ordered by a doctor then they are just as responsible for the consequences as a negligent doctor who didn’t provide sufficient care in the first place. Let’s take it a step further. There should be automatic protections in place for when this happens. Whenever a patient doesn’t receive sufficient care, their insurance company should automatically be investigated by a neutral third party, at the insurer’s expense. If it is concluded that the insurance company is at fault, those responsible for that policy should be subjected to the same consequences as a doctor would. They were likely just doing their job, but this liability would make most people wary of working for bad insurers. This would add more complexity to the system, but there is already so much bureaucracy to find ways to not cover services, most of which is completely unnecessary.
This could even lead to insurers being proactive in caring for their clients. If they are liable for outcomes, they may want to suggest that the patient receive further care that the doctor may have missed. Or, insurance companies could just trust the doctors who are contracted with them. Most doctors have contracts with insurance companies to accept reduced rates. This system could be extended by insurers also considering if they can trust a contracted doctor to not order unnecessary tests and treatments. This may pressure the doctors to undertreat their patients, but they also can make more money by ordering certain treatments. I believe these two forces would more or less counteract each other. Beside, the doctor will still be responsible for malpractice claims. Doing this would cut out all the expense and complexity of claims submission and processing.
If we are to really fix the healthcare system, we cannot accept insurance companies that don’t act in the best interest of their patients. Make coverage decisions based on accepted, evidence-based standards of care and protocols. Make it illegal for insurers to have any specific policies about what they will cover and use evidence from peer reviewed medical journals instead. Make all insurance plans fully cover what their patients need, without tiers, copays, or deductibles. Anything less is not healthcare. By holding insurance companies responsible for their actions, they will have to completely overhaul the system. We can reform the health insurance industry into a force for good rather than evil. It’s time to start demanding that we get the care we are promised.
I know this article is just my thoughts without any evidence. Please post your thoughts in the comments and links to any evidence that support or disprove my claims. I will write more on these topics in the future based on your input. Thanks for reading!