Election May Shift the Agenda, But Our Mission to Expose Big Insurance’s Barriers to Care Remains Unchanged

Tuesday’s election will have significant consequences on what health care issues lawmakers in Washington address after the first of the year – and how they will go about it – but it will not have much influence on the issues we at HEALTH CARE un-covered focus on.

I started this newsletter to raise awareness of how the industry that paid me well for two decades – the health insurance industry – really operates. With every story, we endeavor to pull the curtains back a little more, and that will not change. Big Insurance is an industry of middlemen that has grown to massive size and has become incredibly adept at fleecing both our government and our employers and that has erected barriers that make it increasingly difficult for Americans to get the care they need and at a price they can afford. Those barriers are there for a purpose: to make it less likely insurers will have to pay for medically necessary care so that more money is available to reward shareholders, including the occupants of the companies’ C-suites. 

As we go forward, we will continue to report on what that fleecing looks like, how big it is, and how much it costs us as taxpayers, employees, retirees and patients. And we will continue to report on the consequences of those barriers, namely: 

• outrageously high out-of-pocket requirements;

• excessive and unnecessary prior authorization requirements; and

• inadequate and often poorly constructed and self-serving provider networks. 

By the way, those outrageously high out-of-pocket requirements imposed by Big Insurance are among the reasons Americans are increasingly having trouble putting food on the table and paying the rent. Exit polls I’ve seen showed that around 65% of voters said their main concern was the economy and inflation. The New York Times, in a piece explaining how the Democrats fell so short in races across the country and from the top to the bottom of the ballot, noted that being able to pay the rent was far more of an imperative to working-class voters than pledges to save democracy. Politicians would be smart to do something voters can experience personally, like getting relief from exorbitant deductibles and other out-of-pocket requirements that have put 100 million Americans into medical debt. Voters do not have the ability to vote Cigna and Aetna and UnitedHealthcare out of their lives, but they can vote politicians out of office. And they just did.

While we at HEALTH Care un-covered will continue to focus on what happens or doesn’t happen in Washington and state capitals, we will also continue to focus on what is going on in the private sector – the marketplace – that is promising, that can save both our employers and the rest of us billions of dollars while also making it easier for patients to get the care they need from high-quality health care providers without sinking deep into medical debt. 

I’m proud of the fact that our stories have helped educate lawmakers on both sides of the political divide (as well as employers, advocates, agents and brokers, the media and consumers). We are now seeing real bipartisan support for incremental but extremely important reforms, including legislation that would reduce if not eliminate those industry barriers and make it easier for patients to overcome them. I’m encouraged that Republicans and Democrats alike are cosponsors of legislation to reform the prior authorization process, to force pharmacy benefit managers to change their business practices and operate more transparently, and that would reduce the maximum out-of-pocket requirements for all of us, especially for low- and moderate-income Americans and people with chronic conditions. 

I’m also seeing bipartisan support for efforts to reduce the massive overpayments to insurers that sell Medicare Advantage plans, although Wall Street seems to think the next Trump administration will turn the other way and allow the profiteering to continue. Yesterday, the share price of the big insurers that dominate the MA market rose significantly. We’ll see if Republicans who are true fiscal watchdogs will give Big Insurance the big pass investors are expecting. I’m pretty confident that at least some and maybe many Republicans in Congress will join Democrats in demanding more accountability in the MA program. 

Speaking of investors, the big insurer whose stock price went south after the election was Cigna, which announced plans last year to get out of the Medicare Advantage business. Cigna is now predominantly a PBM: Its Express Scripts business is far bigger and more profitable than the health insurance side of the company, and it no longer has an MA book of business. You can be certain that the results of Tuesday’s election will make it more likely that Cigna will once again consider buying Humana, the second-biggest MA player. 

But as regular readers know, we are not focused exclusively on what’s happening in Washington. Far from it. There is a tremendous amount of disruption occurring in the private sector that has the promise of being more of a headache to Big Insurance than lawmakers in DC or elsewhere. That’s why we launched the “Disintermediation” beat. You’ll be seeing many more stories about health care business leaders and entrepreneurs who are making substantial headway in eliminating the middlemen that add little if any value but enormous cost to the U.S. health care system. We have several profiles and Q&As with these disruptors in the pipeline. So stay tuned.

A final note: I’m grateful for and proud of the diversity of our readership. Our thousands of subscribers span the ideological spectrum, which is remarkable in this day and age. You often disagree – and don’t hold back when you do – but, for the most part, you behave civilly and respect each other’s point of view. We have become a broad-based community of individuals who care about the health and well-being of our fellow Americans and who genuinely want to be a part of the solution. So thank you – especially to those of you who have become paid subscribers, even though all of our content is free.