US Health Insurers Denials

Many many years ago, in a different life and location ....

Comparison Of National Health Systems.

 .... I was given somewhat of a lecture on comparative health systems by a US I.T. worker.

They were arguing that 'socialist healthcare,' as they insisted on calling the UK's National Health System (NHS), was both poor and expensive, compared to the quality of care provided by the US with its mixture of state Medicare (the federal health insurance program for people age 65 plus, and some younger people with disabilities) and private health insurance. 

I also understand that the US also has a Veterans Health Administration, which is an ad-mix of state and patient contributions health care for ex-services personnel - a big thing in the USA where the size of the armed forces make this a benefit to a sizeable number of people. But this didn't feature in the discussion at the time.

Now, whilst I was happy to concede that in some circumstances the care given by some private providers may be better than the local NHS hospital, I still argued that not having to pay for each treatment via variable insurance contributions and coverage, plus often co-payments (as surcharges are defined), would take away the stress having to find money on the spot. I also added that a health system covered by taxes, meant everyone got coverage, and still allowed those that could afford it to go private via schemes such as BUPA (other schemes are available now, but not back then).

I also pointed out that at that time, the French (mix state and insurance) was rated better for treatment and cost than the US system, and was financed by employee and employer contributions, as well as taxes on a variety of revenues. All essential medical services required cost sharing, via coinsurance, co-payments, or balance billing with people buying a modest private complementary insurance to reduce out-of-pocket costs.

Obviously we didn't agree, but they did acknowledge that while they were in the UK, not having to pay for health insurance was something they appreciated. I didn't have access back then to the figures in the top illustration, that indicate the the US system is nowhere near the best of class and indeed US health care is considered an individual responsibility, and not the human right its considered in many developed countries.. As highlighted in Red (and blue for nearest other) the US often compares poorly with others in both cost and outcomes.

• In 2021 the US has the lowest percentage of the population (along with Costa Rica) covered for a core set of health services.
• In 2022 the US spent by far the greatest percentage of GDP at least 4% more than the nearest spender (Germany), and on average 5% more than those countries providing 100% coverage of those core services to their citizens.
• In 2021 the US had the 2nd lowest Average Life Expectancy at Birth (76.4 yrs) with only Italy lower at 74.3 years.
• In 2021 the US had the 2nd highest Infant Mortality Rates per 1,000 live births (5.4) behind Costa Rica with 8.7.
• In 2020 the US had the 2nd highest Maternal Mortality Ratio (deaths per 100,000 Live Births) at 21.1 behind only Costa Rica at 22.0

On other measurements the US fares poorly as well:

• Compared with peer countries, the U.S. spends twice as much on health care but as indicated in the comparison above, has worse health outcomes in many instances.
• US life expectancy at birth is 77.5 years, almost five years shorter than the average life expectancy in other high-income countries. 
• The US has the highest chronic disease burden, highest suicide rates, and highest rate of avoidable deaths.
• Its a fact that no one is entitled to health care in the U.S. as a right, not even children, it has to be bought. Even emergency treatment after being shot for example, is not free (hospitals are obliged to give stabilisation care regardless of ability to pay, but after that you need to pay somehow).
  
• 92 percent of Americans actually have some form of health insurance, but in many cases the coverage is often insufficient. As a result: 41 percent of American adults owe medical debt; 25 per cent have delayed medical treatment due to cost, and 62 per cent of filed bankruptcies are related to medical debt.   
• Even the cost of medicines are exorbitantly high in the US (because its paid by insurance, and the prices are unregulated by the US government). In some cases the costs are up to 256 per cent higher in the U.S. than in other neighbouring countries, prompting many Americans to either skip their medication, navigate informal markets (such as prescription churning), and accessing prescription drugs through other countries (often by smuggling them from Mexico or Canada).  
  

Roll on a few decades from that discussion, and I had had a serious health issues, of which one was a stage 4 Oesophageal (US esophageal) cancer, which in 2024 prices would cost the following to treat in the USA:

• The average cost of surgery for esophageal cancer in the United States is $30,000 (£23,524) - (American Life Fund said $20k to $50k - £15,687 to £39,208).
• Radiation therapy: Uses high-energy beams to kill cancer cells, and costs an average of $50,000 (£39,208).
• Chemotherapy: Uses drugs to kill cancer cells, and costs an average of $100,000 (£78,416)
  

It was too dangerous for me to have radiation therapy (too close to other organs), so I had 6 back to back chemotherapy sessions (spaced 3 weeks apart), and then the operation .... so priced from above list I would assume at least $130,000 (£101,933) worth of treatment required to save my life.

So the arrest of 26 year old Ivy League graduate Luigi Mangione for the murder of UnitedHealthcare CEO Brian Thompson in New York City with the words "deny", "defend" and "depose" written on the empty gun shell casings found at the scene of Mr Thompson's murder, is perhaps not entirely unsurprising. 

These bullets are a reference to the "three Ds of USA medical insurance" - tactics often used by insurance companies to reject payment claims by patients, in America's complex trillion-dollar healthcare industry (an array of providers, for profit and not-for-profit companies, insurance giants, and federal government programmes).

UnitedHealthcare Protests

 Apparently there had already been a number protests outside UnitedHealthcare buildings, such as its Minnesota head office in the past against the insurance firm's policies and denial of patient claims. The "Prior authorisation" clause in all these health insurance schemes or policies allows these companies to review all physician recommended treatments before agreeing to pay for them. These denials of care can be appealed but they are a lengthy process that's incredibly difficult to win and usually aren't.

There is apparently a large pool of anger at the US's increasingly expensive healthcare, that is often pricing many people out of coverage (especially for expensive treatments), and Brian Thompson's LinkedIn history revealed that many customers were angry about denied claims. One woman responded to a post that the chief executive had made about his firm's work on making drugs more affordable.

"I have stage 4 metastatic lung cancer," she wrote. "We've just left [UnitedHealthcare] because of all the denials for my meds. Every month there is a different reason for the denial." .... as you can imagine, it was this post, that caused me to think about that long ago conversation, and my more recent cancer .... apparently as a stage 4 patient, it appears I would have been denied treatment by UnitedHealthcare if I had lived in the USA ... instead, in the UK, I was treated and survived, and I am a least 6 years further on, despite the odds initially being stacked against me ... with no medical bills around my neck!

No one can condone murder, and the company stated that it had received many messages of support from "patients, consumers, health care professionals, associations, government officials and other caring people". But the BBC reported that on-line the response to his murder was at best mixed. One commonly posted comment was  "thoughts and prior authorisations", instead of the phrase "thoughts and prayers," and a clear reference to claim rejections through that clause. While some across the political divide celebrated his killing and many more told tales of rejected health claims.

Research by the Commonwealth Fund (a healthcare research foundation), found that 45% of insured US working-age adults were charged for something in a medical claim that they thought should have been either free or covered by their insurance. 

While 17% (1 in 6) of the respondents said their insurer had denied coverage for a medical treatment that was recommended by their doctor. While an analysis of a sample of comments on X after Mr Mangione's arrest for the murder, carried out by market research firm OneCliq found the vast majority (four-fifths) contained criticism of the healthcare system. Indeed such is the anger against the health insurers that Mr Mangione's X account has also garnered more than 400,000 new followers since the shooting.

Sara Collins, a senior scholar at The Commonwealth Fund said "We find high rates of people saying that their healthcare costs are unaffordable, across all insurance types, even (government-funded) Medicaid and Medicare. People accumulate medical debt because they can't pay their bills. This is unique to the United States. We truly have a medical debt crisis."

The RAND Corporation a non-profit think tank, reported that health insurance premiums are on average $25,000 (£19,600) per family ... effectively a tax on health. But health policy foundation KFF found that while most insured adults (81%), still rated their health insurance as "excellent" or "good," around two-thirds of Americans said the insurance companies deserve "a lot" of blame for high healthcare costs. 

But all the evidence shows that while everything might seem fine with their health plan, until they get sick and need their plan, and then start finding things not covered or treatment denied, meaning that many people face out-of-pocket costs, which could easily be in the thousands or tens of thousands of dollars, which they can be paying too the grave (often with education debts as its companion debt).

Mr Montes-Irueste of People's Action (campaigning for US healthcare reform), said they rejected violence but that "We have a balkanised and broken healthcare system, which is why there are very strong feelings being expressed right now by folks who are experiencing that broken system in various different ways."