Congress must demand transparency from health insurers

Autumn has arrived and, with it, open enrollment season, when every person with job-based health insurance “chooses” a health plan. If you’re like most people, you are struggling to figure out what exactly you get for your insurance premium dollars, how much you’ll have to pay out of pocket when you need care, and which plan is most likely to meet your unforeseeable health care needs.

We are told to “take charge” of our health. Yet, it’s impossible to know whether our health insurance will do right by us. The information you need is not available.

Ever-increasing health insurance premiums bite into our take-home pay and keep wages from rising. Making it worse, as soon as we go to the doctor or hospital, we often face huge deductibles and copays. Sometimes we get surprise bills for care we thought our insurance would cover, like out-of-network doctors at in-network hospitals.

We have little if any clue ahead of time how much health insurers will require us to pay when we need costly care. More than four in 10 of us are skipping medical care because the cost is too high. Medical bills are the most common cause of bankruptcy in the U.S. Some people in debt end up in jail.

Imagine buying a home without first inspecting it for termites and asbestos, a leaky roof, or poor construction. We’d never do that. We’d have no clue what troubles await us. We easily could be throwing away our money and putting our safety at risk. Yet that’s exactly what our health insurers require us to do every fall.

A typical working family today now pays an average of $20,576 in annual premiums with no assurance that their health insurance will cover the care they need. We are buying our coverage virtually blindfolded. We often don’t even know which doctors we’ll be able to see. The provider directories are typically out of date and misleading.

Perverse financial incentives make it especially difficult to trust corporate health insurers. For them, delaying or denying care is not so different from a pharmaceutical company raising drug prices. It’s easy. Every time they second-guess our treating physicians and deny our care, they drive up their profits.

Federal government audits of corporate Medicare insurers (“Medicare Advantage”) -- the best data available on private health insurers -- show cause for serious concern. The U.S. Department of Health and Human Services Office of the Inspector General reported that “audits highlight widespread and persistent … problems related to denials of care and payment.” But, it does not name names.

The Kaiser Family Foundation reports similar concerns with private health insurance in the state health exchanges. On average, health plans denied almost one in five claims in 2017. Some denied as many as 40% of claims. But, Kaiser does not disclose which were the bad actors.

In short, private health insurers may be jeopardizing the health and safety of their members, and we would not know it. We bear the risk. They are inexplicably protected.

The federal government has failed at holding health insurers to account for their bad acts on behalf of people with Medicare, despite years of effort. States, in turn, generally do not have the will, skill or resources to oversee health insurers for working people, let alone to hold them to account for bad acts. The problems with private health insurance appear intractable.

Americans overwhelmingly want and need to know they can get the health care they need at lower cost. Still, most U.S. policymakers look to tinker at the edges of this dysfunctional system. Leading reform proposals do not aim to ensure fair prices or fair play.

It’s time for Congress to rein in health care costs and require health insurers to disclose what they are doing with our premium dollars. For now, you can stop blaming yourself for not being able to make a good health insurance choice. Blame the blindfolds, the insurers who made them, and the congresspeople who have yet to demand that they come off.

Diane Archer (info@justcareusa.org) is founder and president of Just Care USA, and a senior adviser on Medicare at Social Security Works; she is the past board chair of Consumer Reports and serves on the Brown University School of Public Health Advisory Board. Wendell Potter (hello@BusinessforMedicareforAll.org) is president of Businesses for Medicare for All and a former vice president of corporate communications at Cigna.

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