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The Best, Most Revealing Reporting on Our Healthcare System

Our roundup of standout reporting on health care in the U.S. and the struggle to fix it.

Update (6/25): As you wait for the Supreme Court's healthcare decision, here's our roundup of standout reporting on healthcare in the U.S. and the struggle to fix it.

As we wait for the Supreme Court to issue its verdict on the health-care reform law, we rounded up some of the most revealing reporting on the issues. They’re grouped roughly into articles on high costs and those on insurance.

The Cost Conundrum, The New Yorker, June 2009

The article that President Obama made required reading: Atul Gawande’s 2009 piece explores why health-care costs in McAllen, Texas, were higher than almost anywhere else in America. Its citizens weren’t sicker, nor its facilities much better. He concluded that “across-the-board overuse of medicine” was the best explanation for spiraling costs.

In Medicare ’s Data Trove, Clues To Curing The Cost Crisis, The Wall Street Journal, October 2010

One Medicare database, which contains records of every payment the program makes, is “widely considered the single best source of information on the U.S. health-care system.” Yet, thanks to successful lawsuit more than three decades ago by the American Medical Association, this “powerful tool” for sniffing out fraud and abuse can’t be accessed by average citizens. Doctors’ names — and the payments to doctors — are blocked from public view.

A Simple Health-Care Fix Fizzles Out, The Wall Street Journal, February 2010

Studying different medical treatments to see which is most effective may sound like an obvious and promising way to stem America’s rising health-care costs. That's why the government is now pushing the idea. But the solution is not so simple.

Phantom Firms Bleed Millions From Medicare, Reuters, December 2011

Shell companies have scammed Medicare out of hundreds of millions of dollars, but exactly how much, and how often, isn’t clear. Medicare doesn’t have sufficient resources for targeting fraud. Overall in 2010, Medicare lost nearly 10 percent of total payouts, or $48 billion, to “improper payments.”

The Hot Spotters, The New Yorker, January 2011

Another Gawande gem: Could we lower medical costs by focusing on better care for the neediest patients? The tactic worked on New York City crime, and several pioneering programs suggest similar tactics could positively affect our health-care system. (Bonus: Follow the “Surgeon, Writer, Researcher, Dilettante” on Twitter for quality updates on health-care reform.)

Health-Care History: How the Patchwork Coverage Came To Be, Los Angeles Times, February 2012

America’s health-care system, with its emphasis on employer-provided health insurance, is something of an anomaly. (In most countries, the government collects taxes and offers health coverage to everyone.) This article traces the history of how our system came to be, from WWII-era factories to President Lyndon Johnson’s passage of Medicare and Medicaid to Obamacare.

Overlapping Health Plans Are Double Trouble for Taxpayers, The Wall Street Journal,  June 2011

Nearly 10 million poor, elderly Americans qualify for both Medicare and Medicaid. Treatment for these double-counted patients is often expensive. And as the two programs squabble over which should pay, the patients themselves often end up without proper care.

How Insurers Reject You, Slate, February 2010

This dissection of BlueCross BlueShield of Texas’ 2009 coverage guidelines offers a peek at what underwriters consider when deciding who may and may not purchase a policy. In this case, any of 143 diseases triggers an automatic rejection.

Insurer Targeted HIV Patients To Drop Coverage, Reuters, March 2010

Fortis, now known as Assurant Health, was the first insurance company to single out and systematically revoke the policies of people with HIV, often “on erroneous information, the flimsiest of evidence, or for no good reason.” Insurers say the fairly common practice of “rescission,” or revoking policies shortly after issuance, helps them keep premiums down. But regulators and investigators say most cases lack a good reason for cancellation.

Update: We removed an earlier graphic from GOOD. A line at the bottom of the piece notes that it was made by a healthcare technology company, rather than GOOD.

Robert Gustafson

March 30, 2012, 2 p.m.

Consider costs of a typical health insurance company now:

1) They have underwriting costs – they pay an office of highly paid folks to decide whether a particular applicant is a good health risk, and what premium level to charge.

2) They have on-going underwriting costs – they pay folks to decide whether to keep an insured as a client.

If the no-cancel provision and the accept all applicants provisions are kept, costs #1 and #2 will disappear. The health insurance industry will concentrate on efficiency rather than avoidance of sick people for their corporate profit and/or executive salaries.

If the individual mandate is struck down, but the ‘no-cancel’ and ‘accept all applicants’ provisions remain, then health insurance premiums will have to go up because the insurance companies will be covering more sick people. The healthy people will drop* their coverage because it will be much more expensive . The effect on health care in the US will be to make it worse than it is now.

Health care costs in the United States on a per person per year basis are double what the citizens of many other countries pay, countries with better health outcomes than the US as measured by longevity
and infant mortality. Much of this increase in cost is related to the structure of the health insurance business in this country. The current features of the PPACA help to align US policy with health policy in other countries. There is a good chance that overall health care costs will also align and decline.

Keep the Patient Protection and Affordable Care Act intact.

        Robert Gustafson

* (or move to Massachusetts)

Our healthcare system is broke, for 50 years we have had big government meddling in health care and have fixed nothing!

Our own government is broke and will not be able to meet its obligations without massive and punitive tax increases and like Greece may not be able to sustain its obligations!

When I was a child my parents were poor and I had exceptional healthcare because we negotiated with the doctor directly.  Thus private healthcare accounts that are tax-deductible plus some sort of catastrophic health care insurance is the only logical possibility.

Put it simply, government is not the answer!  Hopefully the American people are not stupid and the Supreme Court will be kind to our Constitution.

As someone only able to obtain catastrophic health insurance coverage, I have attempted to negotiate with providers for services.  Their cash pay charges are still quite high but lower than what they usually bill.  But what they won’t (or can’t) tell you is that insurance companies have often negotiated an even lower rate.  That means that the uninsured may be paying more than their fair share for services, thus effectively subsidizing the insurance companies.

The only reasonable approach is to provide a modest level of basic health care services to all, with a single payer that sets or negotiates reasonable fees for services and rewards for favorable outcomes.

Robert, I have the opposite view:  Look at the insurer’s business model.  They take a high, regular fee (the premium) that, over your lifetime, is greater than their overhead and the amount of money to cover your needs.  Their entire purpose is, at best, floating you a loan in a crisis, where you make payments before you can borrow.  At worst, it’s outright fraud.

Any system that looks to insurance, therefore, is more expensive than it needs to be and benefits one of the most blatantl parasitic parts of society.  (Not the people, the organization.  They take payment and never produce anything, and can’t survive without their customers.)  What the Act plans to do is sell out all the healthy young people to make it affordable to the parasite to also take money from the old and infirm.

There are two possible real solutions, depending on your economic leanings.  I’d be happy with either extreme or some hybrid form I can’t envision.

At the ultra-capitalist end of the spectrum, drive a stake through the heart of the insurance industry and the AMA.  They’re private organizations with zero oversight that manipulate the market so that it costs twelve thousand dollars for a doctor to fix a broken arm, something a Boy Scout will do for, like, a box of cookies and a pat on the head.

What Mark hints at is that you can no longer negotiate with your doctor because he’s not allowed to do so.  She’s unionized, and if the union (the AMA) catches her, she could potentially lose her license.

I’d add killing, or at least wounding, pharmaceutical patents.  They’re anti-capitalist monopolies over life and death and another cost driver with zero need.

Yeah, yeah, Pfizer might not produce the next wonder drug if they can’t be guaranteed they’ll recoup their investment.  My response is to look how much they made off Lipitor and are still trying to keep their monopoly even now that their patent has expired.  Also look at how many unreliable and even dangerous drugs make it to market in hopes of cashing in big.  They need protection the same way a king needs protection from his subjects.

The approach is to break the trusts that are making it impossible for an illegal immigrant to afford healthcare.  When a broken bone can be set for the price of dinner, we can talk about insuring against the really scary stuff or other solutions.

On the socialist side, Medicaid works for most of the people on it, so just make it bigger.  You go to the doctor and she can bill the government.  Problem solved, it’s Miller Time!

Someone needs to figure out how to pay for it, but if you don’t trust the free market to solve the problem, we can always stop blowing up Arab civilians for a few weeks or stop subsidizing oil and I’m sure the money will show up somewhere.  Or form a Super PAC, since they’re all the rage and apparently poop out hundred-dollar bills.

Any solution that pretends to be socialist in nature, but puts a private corporation (especially one that, as noted, is inherently parasitic) in between you and service (or pretends to be capitalist, but has the government as a competitor), is going to be the absolute worst of both worlds.  All the bureaucracy and all the profiteering, without solving the problem that there are middle men everywhere scamming the system for a quick buck.

What I’d like to see is mostly the first solution (free market, no price-fixing or insurance), with a no-questions-asked government-funded “safety net” for any serious disease or injury.  I’ll happily pay taxes to foot the bill for someone’s cancer treatment as long as the money is going for treatment rather than buying some executive a new helicopter.

Robert Gustafson

March 30, 2012, 3:35 p.m.

John, I basically agree with much of what you say. The trick is coming up with a solution – one can look at the health care structure of other countries as a guide. It is not difficult to determine what is different. Check out T.R. Reid’s book and the two PBS shows for background.

You mention free market. John Hain earlier in this blog wrote how difficult it is for an individual to negotiate with a big insurance company. The individual can go to any number of different insurance companies – they are free to choose. However, in practice, anti-trust laws not withstanding, the prices obtained from different insurance companies are pretty much the same – high.

What government can do is regulate these insurance companies. This is done now and doesn’t really work very well. Perhaps being regulated by 50 different states allows the big companies to exert some pressure here and there. A campaign contribution for a state senator here, a representative there.  There are limits to regulation.

However, the government can change the rules of the game. Saying that insurance companies cannot refuse an applicant or cannot pitch them over the side when they cost too much changes the rules. Also saying that all US residents have to sign up with an insurance company or face a fine is a rule changer. In combination, these rules create a free market arena where insurance companies can make money, and clients have a clear view of the product they are buying.

A small group in my state have been working on single payer health care for more than 15 years. There is nothing I read here that even discusses the fix for the problem. PNHP.org, the fastest growing nurses/doctors group in the nation has been supporting a single payer health care SYSTEM. The patchwork of for profit insurance companies put in place by Richard Nixon are robbing the american people. 45cents out of every health care dollar is taken for CEO’s, shareholders and advertising. WE are spending double what any industrialized, civilized nation spends and we have the worst coverage. Our health care outcomes are behind Cuba and Costa Rica! The US is 37th in the world in delivery of health care.

When Obama was elected he asked citizens to tell him what we wanted. Single payer was always either first, second or third place. But when the health care debate went forward and the teabaggers (many medicare receivers) were told by ALL the corporate media that there would be less funds, death panels etc…and not one corporate media or press ever discussed the issue of single payer. Single payer is the only system that is cost effective, covers everyone and there is enough money in the system, it would not only cover medical, dental, optical, long term care, prisoners, aids you name it. Imagine not having to pay out of pocket for all those other medical issues?

An independent study was done in Delaware and they looked at every insurance plan. They concluded in the end that if Delaware would go to single payer, they could cover everyone for every medical issue and still save the state conservatively $4 million. Vermont is doing their single payer system right now, and Delaware will have theirs before the legislature this session is over.

Robert Gustafson

March 30, 2012, 4:54 p.m.

Yes spktruth200, a single payer system is used in many countries around the world and it generally works pretty well - again, refer to the PBS documentary http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/  Not all countries use single payer - some use multiple insurance vendors, but in a very structured arena.

A single payer (‘public option’) was going to be part of the current law, but was quietly dropped. (I wonder why?). Obama was able to pass the current law by a hair. Momentarily, the Democrats had 60 votes in the Senate and were able to overcome a Republican filibuster. At that moment, there wasn’t enough political room for the ‘public option’.

The American health care is nothing but a joke. Low wage workers are unable to pay for health insurance due to our screwed up system.

Many first world nations cover all of their citizens with health care. No matter how much they earn, everybody receive the same type of care.

Here in the USA if you are rich, working for the government, or a freeloder politician you can get the best health care covereage and care in the world for basically nothing. The rest of the people don’t matter. If they can’t pay we take away their homes, bank accounts, and bankrupt them to the last penny. We do this so Health Insurance companies can make profit,
so their CEOs can receive their 80 million dollar salaries and bonuses.

Health Insurance for the American people should be NOT FOR PROFIT.
People in Germany, France, England, Switzerland, Sweden, and many other countries agree with their government , that health care is a humane thing a government can do for their people.

Here in the USA we looking at it differently. We put greed before humanity.
There is plenty of solution for all Americans to have a decent health care but your government doesn’t want you to know.

After all how could the lobbyist vine and dine our politicians if they would represent the American people and not the corporations?

Robert Gustafson

March 30, 2012, 10:45 p.m.

Yes, Gabor, the American health care system is a joke. But not a funny joke for too many people.

Not for Profit - is not sufficient. Blue Cross is run as a non-profit corporation in many states. Their premium levels are higher than many for-profit health insurers in the same area. Their executives get large salaries. They pay their underwriters for rejecting sick applicants. Same old, same old.

But that is the way the system is, and it won’t change until enough people (voters) get excited about meaningful change. The politicians can’t do it alone. They are too busy raising money for their next election campaign.

Check out http://www.thisamericanlife.org/. The program that was broadcast earlier tonight and will be broadcast again tomorrow (March 30-31, 2012) talks about the problem:

“Take the Money and Run for Office” - This American Life - podcast of the broadcast available Sunday 7pm (timezone?)

The new health plan - Obamacare = Patient Protection and Affordable Care Act - does represent a change to the status quo. Whether it gets a chance to prove itself - is up to the Supreme Court now.

Robert Gustafson

March 30, 2012, 11:03 p.m.

More on the ‘money in politics’ story has been reported by Planet Money - http://www.npr.org/blogs/money/

Planet Money was also involved in the This American Life story this week. You can see some excerpts at: http://www.npr.org/blogs/money/135573355/this-american-life

Louis Lombardo

March 31, 2012, 6:50 a.m.

Bravo!  Thanks to Pro Publica and to readers who commented.  Keep up the good work.  We the people need you.

My 22 year old son is working as an English teacher in Taiwan (few good jobs for liberal arts college grads in the US).  He’s the paradigm of the young healthy person that Justice Scalia says would be “stupid” to buy health insurance - young, physically active, not major existing conditions.  Except that he’s had a to visit the doctor a few times. Once, he sprained his ankle. Once, he came down with a nasty bug. And recently, a strange lump in his arm. The last one was scary. He had minor surgery on his arm to remove the lump and have it biopsied - negative, nothing to worry about.  The latter procedure involved 4 doctor/hospital visits, a sonogram, a biopsy and pain medication. Out of pocket costs to my son, ~$25. He had complete choice of hospitals and doctors (because the out of pocket cost to him was the same where ever he went) and was quite happy with the care he received.  I had a similar procedure 10 years ago in Los Angeles. My out of pocket costs with excellent insurance, hundreds of dollars and if I’d gone to an out of network hospital, potentially thousands.
According to the Reid book, Taiwan adopted a uniform health system 10 years ago.  Discussing the difference with his doctor (educated in San Francisco), my son was told that the US system is much better for the doctors because they make much more $, but that the Taiwanese system is much better for the patients.  When he expressed his wonderment to his friends about the low cost and ease of care he received, my son said his friends (Taiwanese and Canadian) thought he was weird. To them, no big deal that medical services are readily available to any one at low cost and without delay or restrictions.

If he were home in the US, thanks to the reform act, he would still have been covered under our insurance policy.  If the Act is struck down and he comes back to the U.S., now I’ve got to worry.  The catastrophic coverage we purchase for his sister when she got out of college wouldn’t have covered his surgery.  I agree with Reid that until we understand that medical care is a moral issue, we will not solve this problem.

It’s revealing that the articles sited as “The Best, Most Revealing Reporting on Our Healthcare System” do not include such facts as:

1. 20% is the overhead guarantee for private, for-profit insurance companies - the overhead rate guaranteed under ACA and common with private for-profit insurance companies today
2.  4% is the government’s overhead rate for Medicare.
3. 16% is the potential savings with a single payer system.

That seems worth including in any reporting on “Our Healthcare System”.
But is strangely absent from publications Propublica lists as “The ...Most Revealing Reporting”.

As long as the media is complicit in the propaganda, voters will not know the facts, as this evidenced by the articles in this list of “The Best, Most Revealing Reporting on Our Healthcare System”.

The 20% available to (or rather guaranteed) under ACA can be used by the private, for-profit insurance industry for “marketing” and “sales” (though they have ‘mandated customers’); staff to deny you health care services; representation on Boards to set rates and decide what health care services will and won’t be covered; “profits” generated by no actual value-added health care services; CEO bonuses and, of course, donations to sympathetic politicians.

We should be able to rely on groups like Propublica to provide this type of information.

Robert Gustafson

March 31, 2012, 12:28 p.m.

Yes, Gabor, the American health care system is a joke. But not a funny joke for too many people.

Not for Profit - is not sufficient. Blue Cross is run as a non-profit corporation in many states. Their premium levels are higher than many for-profit health insurers in the same area. Their executives get large salaries. They pay their underwriters for rejecting sick applicants. Same old, same old.

But that is the way the system is, and it won’t change until enough people (voters) get excited about meaningful change. The politicians can’t do it alone. They are too busy raising money for their next election campaign.

Check out this week’s broadcast of ‘This American Life’. This program (March 30-31, 2012) talks about the problem:

“Take the Money and Run for Office” - This American Life - podcast of the broadcast available Sunday 7pm (timezone?)

The new health plan - Obamacare = Patient Protection and Affordable Care Act - does represent a change to the status quo. Whether it gets a chance to prove itself - is up to the Supreme Court now.

Christopher Hughes,MD

March 31, 2012, 5:51 p.m.

I still hear from conservatives about moral hazard and skin in the game type arguments, so may I recommend Malcolm Gladwell’s great article, The Moral Hazard Myth.
http://www.gladwell.com/2005/2005_08_29_a_hazard.html

I think I see the problem here. Our system is based on PROFITS for the insurance companies and the doctors, while most of the rest of the world is NOT based on profit. So, trying to make an American system work like theirs does, while doing nothing about the profit side of it is simply not going to work. Maybe, a law saying that ALL insurance companies must be non-profits might work. Requiring insurance companies to accept ALL applications, regardless of pre-existing conditions, with no life time limits on coverage, would solve the biggest drawbacks. As for the so-called ‘death panels’, I think you really need to read the law as it was enacted. There are provisions for limiting the amount and kinds of treatments available for the elderly. Maybe it isn’t a ‘death panel’ per se, but it sure isn’t free market, either. Once the HC bill is ruled unconstitutional we need to start working on a whole new plan that WILL work and WILL be constitutional. We should have analyzed the best of the foreign plans and built something that corrected the inherent flaws in them. I think the Medicare idea is pretty good, too. IF we can afford to pay for it! By the way, I am a Republican and I firmly believe that we CAN create a working system that will be acceptable and effective for everyone. It will require NON-PARTISAN efforts on both sides of the aisle, something we haven’t seen much of lately. Congress is acting like a bunch of grade school kids, fighting over territory, and our President hasn’t done anything to discourage them. I am ashamed of all of them, Republicans and Democrats alike. We elected them and pay them for services we are not getting. If they can’t do the job we hired them for, we should fire the lot of them and start all over. That’s just my opinion, for whatever it’s worth.

The Obama administration has said it has ‘no back-up plan’ should ACA be found unconstitutional.

Before the Tea Party-funded gun-totters stormed the ‘town halls’ in the summer of 2009:

Seventy-two (72%) percent of us supported “a government administered insurance plan - something like Medicare for those under 65—that would compete for customers with private insurers.”

(CBS/New York Times poll June 2009)

Of course, Obama et al sat on their hands during this period allegedly ‘letting the system work’. ACA is the product of its ‘work’.

So, now, we will see whether Obama wanted universal health care or an nsurance subsidy program for the private for-profits.

If Obama does not have a ‘back-up’ and sits on his hands again, we will know he wanted an insurance company subsidy and failing that he cares nothing about universal health care.

We will soon see.

there’s a dead link for the last WSJ story.

Here’s why insurance companies went up when ACA was passed:

Insurance companies will see many of their ‘costs’ decline (as mentioned by another person on this post)

However,

ACA guarantees overhead to insurance companies at approximately the same rate they enjoy now.

While their work will decline, their overhead will remain guaranteed under ACA.

What can they spend their ‘overhead’ on?

The government guaranteed 20% “overhead” can be spent by the private sector for-profits on: “marketing” and “sales” (though they have ‘mandated customers’); staff to deny you health care services; representation on Boards to set rates and decide what health care services will and won’t be covered; “profits” generated by no actual value-added health care services; CEO bonuses and, of course, donations to sympathetic politicians.

How fun is that !

No wonder the insurance companies’ stocks went up.

And now that all that’s swept under the rug, ...

The Obama administration wants go after the cost of actual health care services - Doctors, nurses, physicians assistants, labs, etc. - and cut those costs ... .

While guaranteeing insurance company overhead.

Really. You want ACA to stand?

ACA is a Republican right wing corporate plan for a reason: it’s chockablock with corporate welfare and seeks to reduce cost - not by getting rid of non-value-added insurance company waste , but - actual health care services.

Pauline Dyson

April 6, 2012, 6:25 a.m.

As a pro-national health single payer advocate for some thirty years, I read with relish all the New Yorker articles listed above when they were first published. The general public fearful of government control “of our bodies”, however, need convincing from folks like me who have lived in countries with much more effective and humane medicine for all citizens.
Even more compelling than stats and anecdotes of travelers are the personal stories of people caught in the medical insurance trap.  President Obama often sighted his own mother’s case during the last election.  Even sadder is the story told by an Assoc. Prof. at MIT whose op-ed piece DOWN THE INSURANCE RABBIT HOLE in the NYTimes, April 5th.  She rebukes Justice Scalia’s for saying that the young will buy insurance when they think they will risk high medical bills.  Her sad tale of a relative who is a healthy 32 year old pregnant Californian one day and a paraplegic the next as a result of an accident.  “Her best hope is the survival of the Obama reform.”

How would have guessed that union thugs would solve the cost control issue in American Health Care?

Common sense tactics - prevention, education, and evidence-based quality control decisions on care-providers - have health care costs consistently DROPPING for a midwest local of the Operating Engineers.

http://www.aflcio.org/Features/Innovators/Bending-the-Health-Care-Cost-Curve

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