The Center for Public Integrity

If you have no idea what you’re paying good money for when you enroll in a health insurance plan, there’s a good reason for that: insurers profit from your ignorance. And they’re waging an intense behind-the-scenes campaign to keep you in the dark.

In my first appearance before Congress after leaving the insurance industry, I told members of the Senate Commerce Committee that insurers intentionally make it all but impossible for consumers to find out in advance of buying a policy exactly what is covered and what isn’t and how much they’ll be on the hook for if they get sick or injured.  Insurers are quite willing to provide you with slick marketing materials about their policies, but those materials are notoriously skimpy when it comes to useful information.  And the documents they provide after you enroll are so dense few of us can understand them. 

In the months following my Senate testimony, lawmakers drafting health reform legislation included a provision requiring insurers to both provide comprehensible disclosures of health plan benefits and make that information available to anyone shopping for coverage. Despite repeated attempts by industry lobbyists to get that provision stripped out of the final bill, the Affordable Care Act as signed by President Obama last year requires that all private health plans provide consumers with a concise and understandable Summary of Benefits and Coverage (SBC) form. In addition, they must provide a uniform glossary of medical and insurance terms.

If you think that sounds like a reasonable request, you’re not an insurance company executive who is rewarded more for meeting Wall Street’s profit expectations than assuring that consumers know what they’re buying.

Members of Congress and the Obama administration have assured us that on January 1, 2014, junk health insurance plans — which offer only the illusion of adequate coverage to the millions of Americans enrolled in them — will become a thing of the past.

Among those who clearly don’t believe those plans are headed for extinction are the insurance companies that market these highly profitable plans and the employers that buy them — primarily restaurant chains and retailers with high employee turnover.

If I were President Obama, I would send one of my aides to the Chicago suburbs later this week to see first-hand just how determined these companies are to continue selling these plans — which are euphemistically called “mini-med” and “limited-benefit policies” — long past 2014.

On Wednesday, the third annual Voluntary Benefits and Limited Medical Conference will open at the Marriott Renaissance Schaumburg Convention Center, not far from Chicago’s O’Hare airport. In just three years, this conference has grown to be a very big, three-day extravaganza. According to the conference Web site, it will “bring together all the players in the industry, from employers and benefits managers, to insurance agents, consultants, brokers, insurance companies, TPAs (third-party administrators), and enrollment firms.” 

All you have to do is spend a few minutes on the Web site to get an understanding of just how much money there is to be made selling inadequate coverage to naive consumers. You’ll see all the big names in the insurance world among the attendees and exhibitors, including the very biggest — Aetna, Blue Cross and Blue Shield, CIGNA, Humana and United — as well as dozens of restaurant and fast food chains and other employers of low-wage workers.

As I wrote last week, Maine and California are taking radically different approaches to implementing health care reforms within their boundaries. While the GOP-controlled government in Augusta has passed legislation that gives health insurers far more control of the health care system than they’ve ever had, lawmakers in Sacramento are taking California in the opposite direction. They’re moving rapidly to implement the federal Affordable Care Act, and if Insurance Commissioner Dave Jones and many of his former colleagues in the legislature have their way, California will be among the first states to implement a single-payer system in the years ahead. I spoke recently with Jones about the benefits and shortcomings of the federal reform law and why, even as commissioner of insurance, he continues to be an ardent single-payer advocate.

iWatch News: After nine months in office, what’s your overall assessment of the health insurance marketplace in California?

The lobbyists for U.S. health insurers surely have to be feeling a little uneasy knowing that thousands of Occupy Wall Street demonstrators who have been marching and protesting in Washington as well as New York and other cities might target them in the days ahead. After all, the headquarters of the insurers’ biggest lobbying and PR group, America’s Health Insurance Plans (AHIP), at 601 Pennsylvania Avenue, N.W., is just blocks away from Freedom Plaza, where the demonstrators have set up camp, and problems with health insurers appear to be near the top of the list of protesters’ concerns.

Health Care for America Now, an umbrella advocacy group that played a key role in the health care reform debate, last week analyzed the 546 comments that had been posted by then on “We are the 99 percent” Tumblr site. It found that 262 of the comments mention such problems as getting denials for doctor-ordered care from their insurance companies and having to forego treatment because of hefty out-of-pocket costs.

In my book, Deadly Spin, I wrote about how the “Wall Street takeover” of the American health care system has created many of the problems mentioned in the Tumblr site. I also described how AHIP offices have often been command central for developing and implementing coordinated efforts to derail health care reform efforts in the past and how the organization helped shape major provisions of the Affordable Care Act, which Congress passed last year.

Deb Richter knows from years of experience that you can’t take  “no” as a final answer from your health insurer. You’ve got to fight back.

As a doctor, Richter has gone to bat for many patients after they received denial notices from their insurance companies for care she knew they needed. I wrote about her advocacy for both patients and for a single payer system in Vermont last May.

Now Richter has a new patient she has to stick up for: herself. She recently learned she has cancer, and is discovering that, like many other Americans with life-threatening illnesses, she has to battle her insurer as well as her disease. And she is learning that even doctors have no immunity from the practices insurance companies engage in every day to avoid paying claims.

Last week I wrote about the importance of being a squeaky wheel when your insurer has decided it doesn’t want to pay for expensive treatment, even if your doctor believes your life might depend on it. I noted that most insurance firms have special departments to deal exclusively with what they refer to as “high profile” cases. Squeak loud and long, if necessary. You’re more likely to get the grease. Richter has every intention of being designated “high profile.”

Dear Wendell:

I received a letter from my insurance company stating that they are investigating whether my breast cancer is a pre-existing condition. Mind you, my mammogram one year ago was completely normal. Even when they went back and looked at it again this year and compared it to the positive one I just got, they stated there was no evidence of malignant changes on last year’s mammogram.

The Kaiser Family Foundation just released the findings of its annual survey of businesses to determine how much the cost of employer-sponsored health coverage has gone up. There were some unexpected findings.

One was that the average cost of annual premiums for family coverage is now more than $15,000. The 9 percent increase in the cost of health insurance over last year caught many people by surprise, because it represented a bigger hike in premiums than in recent years.

What seems clear is that insurers decided last year to charge their customers considerably more than necessary this year to be able to meet Wall Street’s profit expectations; insurance companies are also concerned that such increases will be more difficult once health care reform is fully implemented in 2014.

Here’s another surprise. Kaiser found that 50 percent of small employers are aware that they are now eligible for a tax credit from the federal government — thanks to the Affordable Care Act — if they provide subsidized coverage to their employees. I can hardly believe the awareness of the tax credit is that high.

As I have traveled across the country in recent weeks, speaking to a wide range of audiences, one thing has become abundantly clear: the provisions of the Affordable Care Act already in effect are anything but abundantly clear to people.

That’s because opponents of health care reform have won the public relations battle in defining the Affordable Care Act.

While the most recent Kaiser survey did not seek the views of the general population nor ask employers what they think or know about the Affordable Care Act, other polls show that advocates of the new law have been losing ground in the battle for public support.