Welcome to HEALTH CARE un-covered (formerly Wendell Potter NOW)

On March 23, 2010, President Obama signed a bill into law that had two especially important words in its title. It was called the Patient Protection and Affordable Care Act. 

Those first two words quickly fell out of use – and sadly for good reason. Patients are not being protected, and one can make a strong case that the word “Affordable” is not fitting, either.

While the law did make it illegal for health insurance companies to continue blackballing patients because of prior or existing medical conditions and purging patients when they got sick, it allowed them to raise other barriers to insurmountable heights. 

As a result: 

• 43% of working-age adults were “inadequately insured” last year, according to the Commonwealth Fund, primarily because the law allows insurers to shift more of the cost of care to patients every year. 

• Millions of American families, despite paying ever-increasing premiums, have become “functionally uninsured” as their out-of-pocket requirements have soared.

• 100 million of us – including at least 70 million who are “insured” - now have medical debt. Many are forced into bankruptcy. 

• Patients and their doctors are getting more and more denial notices as insurers have ratcheted up their prior authorization demands to avoid paying claims and boost profits.

• And patients in rural communities and big cities alike are finding that the doctors and hospitals they prefer – and that in many cases provide a higher quality of care – are off limits because of deals insurers strike with big physician groups, hospital systems, and drug companies to construct their proprietary provider networks and drug formularies. And those deals have allowed the prices of many medications and a stay in the hospital to skyrocket. 

Everybody wins – except us.

A big reason Big Insurance has been able to get away with this – even as they report record profits year after year – is a lack of scrutiny and oversight by the media, our lawmakers, and our employers.

That’s about to change. 

Welcome to HEALTH CARE un-covered. 

I started this newsletter a little over a year ago as a project of the Center for Health & Democracy to call attention to out-of-control profiteering in U.S. health care and what that means to average folks. And, importantly, to identify potential solutions. 

Our mission: 

• to uncover the facts and figures big insurers and health-care providers try to hide from us and then connect the dots, 

• to tell the stories of people who are going broke and dying prematurely, even if they have health insurance; 

• to provide information to lawmakers, employers, and reporters – and you – that we never get from industry lobbyists and flacks like I used to be; and

• to identify and advocate for solutions.

Without any promotion, the newsletter has grown way beyond my expectations, proving that there is a hunger – from Main Street and the C-Suite to Capitol Hill and newsrooms – for the kind of reporting and analysis we are doing. Our thousands of subscribers include Members of Congress and their staffs, state lawmakers, employers, reform advocates, philanthropists, and some of the country’s most prominent health-care journalists.

But two questions I keep getting are: Why aren’t there more “insiders” and former insiders willing to speak out and tell the truth? And what can be done to change a health-care system that is becoming increasingly expensive and off-limits to so many of us? 

What I have found is there are many like me. They’re willing to share what they know, to pull the curtains back as I’ve been trying to do, and help us find the right paths forward. They just need encouragement to speak out and a platform to speak from.

Health Care un-covered will be that platform. 

In the coming weeks and months, you will hear from people like me who rose to positions of leadership in the industry – and saw too much for them to stay on the job and to keep quiet.

My team and I have pulled together an impressive list of former insiders, including:

• a former top executive of one of the country’s largest “nonprofit” insurers; 

• a former executive who managed prior authorization for a major company; 

• a former medical director of one of the largest pharmacy benefit managers (PBMs) in the country; 

• a former executive who managed physician contracting for one of the big five for-profit insurers; 

• an official who managed health benefits for hundreds of thousands of state employees and their dependents;

• a former executive who devised strategies to sell insurers’ money-making “disease management” and “wellness” programs to employers.

And that’s just to start. 

Other contributors will bring home the consequences of a system that is increasingly expensive and unfair, especially in rural America and in Black, Latino, Asian, and Indigenous communities, but also to middle-class families regardless of where they live or the color of their skin. Another area of focus will be government-funded programs, especially Medicare and the privately owned Medicare replacement plans marketed as “Medicare Advantage.”

In addition to writing for this newsletter, I spend a lot of time talking with Members of Congress on both sides of the political divide, with state and city officials, employers, and reporters. What I have found is a lack of understanding of how things really work in health care and a scarcity of ideas about how to move forward – especially in the face of the billions of dollars entrenched special interests spend on their lobbying and PR campaigns to protect their profits. 

Even our biggest employers – which until recently were the biggest customers of Big Insurance (they’ve been replaced, as I’ve pointed out, by government payers) – are unaware of the extent to which they, too, are being taken to the cleaners. But they do know that the current system is unsustainable for even them.

The top executives at nearly 90% of large employers surveyed by the Purchaser Business Group on Health and the Kaiser Family Foundation last year said they believe the cost of providing health benefits to employees will become unsustainable in the next five to 10 years. Almost as many – 85% – expect the government will be required to intervene to provide coverage and contain costs.

Large employers “have reached their limit,” said PBGH CEO Elizabeth Mitchell. “They’re tired of pouring tons of money into a broken health care market that delivers uneven quality at bloated costs.”

At HEALTH CARE un-covered and the Center for Health & Democracy, we will educate and work with employers of all sizes to develop solutions and reform strategies to push back against what we all know will be massive opposition from insurers and providers who profit from the status quo. 

“Employers, who foot much of the nation’s health care bill, could be a powerful counterweight” to the inevitable pushback, said Larry Levitt, KFF’s EVP for health policy. 

We will continue to analyze the earnings reports of big corporations to unearth the details they try to obscure and provide reporting you’re not finding anywhere else, like these stats:

• Cigna, where I used to work, now gets far more revenue from its PBM (Express Scripts) than from its health plans; 

• Caremark, the PBM that CVS bought a few years ago, contributes more to the company’s revenues than either Aetna, which it bought in 2018, or its 10,000 stores.

• UnitedHealth Group, which owns another one of the big three PBMs, now gets more than 70% of its health plan revenues from government programs (taxpayers). At Humana, where I also used to work, that number is now north of 90%.

Meanwhile, despite the PPACA, premiums have increased so much that more and more employers are throwing in the towel. As recently as 2000, 69% of U.S. employers offered health coverage. It is now just barely above 50%.

No wonder: The cost of employer-sponsored family coverage has increased from $5,791 in 1999 to $22,463 last year. 

Workers who can still get health insurance from their employers are contributing ever-growing percentages of that total – and paying more and more out of their own pockets before their coverage kicks in. Behind closed doors, as I have written, insurers call this intentional practice “benefit buydown,” and it’s a big reason why 100 million of us have medical debt. 

The PPACA allows out-of-pockets to increase every year. Under that law, a family could be on the hook for $18,200 this year before their insurer will pay a dime. That’s up from $12,700 since 2014 when many of the provisions of the law took effect. That’s a 49% increase in nine years, far outpacing inflation. 

As a result, according to a recent survey by the Commonwealth Fund:

• 44% of those who purchased coverage through the individual market and (ACA) marketplaces were underinsured; 

• 46% of those surveyed said they had skipped or delayed care because of the cost;

• 42% said they had problems paying medical bills or were paying off medical debt;

• Half (49%) said they would be unable to pay an unexpected medical bill within 30 days, including 68% of adults with low income, 69% of Black adults, and 63% of Latino/Hispanic adults. 

Meanwhile, even as nearly 30 million of us remain uninsured, big, for-profit insurers are posting record-breaking profits (UnitedHealth alone made $28.4 billion in profits last year) and are spending a big chunk of what we pay them – as individuals, employees, and taxpayers – to repurchase shares of their own stock for the sole benefit of their shareholders. That’s money that could be used to lower premiums and out-of-pockets and make sure patients get the care (and medications) their doctors know they need.

Also meanwhile:

• Our life expectancy is declining, especially in rural America and communities of color.

• More and more of us are in desperate financial straits and dying of “diseases of despair.”

• Far too little is being spent to keep us healthy and out of the hospital and grave. Just this month, the Centers for Disease and Prevention cited a new study that predicts a nearly 700% increase in Type 2 diabetes diagnoses in Americans under the age of 20 through 2026 if the anticipated upward trend continues. The increase will disproportionately affect minority populations. 

• Physician and nurse burnout is rampant. Over 330,000 health-care workers left the workforce in 2021 alone, including 117,000 doctors, in large part due to the crushing burden of administrative requirements from having to deal daily with a multitude of insurance options and the interference of insurance companies in patient care decisions. And we are losing many of them to suicide. The suicide rate among physicians is the highest of any profession: more than one doctor commits suicide every day.

I could go on – and will, through HEALTH CARE un-covered – along with expert help from many others who are fighting the good fight on behalf of patients and all of us who are paying far more for health care than we need to. 

What we essentially will be doing is laying the predicate, borrowing a term from the legal world, providing the evidence – and connecting the dots – so the people we vote for and work for can begin mapping our way forward. And with our colleagues at the Center for Health & Democracy, we will work to figure that out. We will be developing and advocating for solutions in both the public and private sectors. So sign up and stay tuned. 

(Editor’s note: Some of you who have followed my work know that HEALTH CARE un-covered is an expansion of a project I adopted last year. Un-covered began as an initiative to expose how big insurers “have put their corporate wealth over the nation’s health—at the expense of patients and providers alike.” You’ll still be able to find the many investigative reports and analysis pieces on the Un-covered website.)