The Center for Public Integrity

For the first time in a long time, my former insurance colleagues and I agree on something: it’s time for affordability.

Health insurers’ big PR and lobbying group, America’s Health Insurance Plans, has launched a slick new campaign, complete with compelling graphics and pithy sound bites, to persuade lawmakers that they need to take immediate action to prevent insurance premiums from going up more than usual.

But while we agree that lawmakers do indeed need to focus on affordability, we disagree on what they should do. Insurance executives want Congress to get rid of some of the most important consumer protections in the Affordable Care Act, a.k.a. ObamaCare. I believe it’s time to focus on the value—or lack thereof—that private health insurance companies actually add to our health care system.

Several years ago, a coworker asked our CEO during a staff meeting what kept him up at night. He responded with a single word: disintermediation.

Merriam-Webster defines disintermediation as “the elimination of an intermediary in a transaction between two parties.” So what my boss was saying was that sooner or later, Americans might reach the conclusion that private insurers are no more essential than travel agents (remember them?), and that by dispatching health insurers to the history books, we could reduce spending on health care by billions if not trillions of dollars.   

Much of what I was paid to do in my former job was to create and perpetuate the impression that insurers are “part of the solution” and “add value” to the system. I put those words between quotation marks because they were used repeatedly by my CEO and other industry leaders and became our mantras, especially in conversations with policymakers and the media.

As Ronald Reagan once famously said, “There you go again.”

The culprits in this case are health insurance companies that want to change ObamaCare so they can keep selling highly profitable junk insurance to young people and keep charging older folks so much in premiums they have little money left over for anything else.

What’s happening now is a repeat of the tactics insurers employed during the final weeks of the health care reform debate. Back then, they papered Washington with a flawed “study” warning that premiums would soar if lawmakers ignored their recommendations. And now insurers are once again disseminating a new study with similar predictions. This time they’re trying to convince us that coverage for all young adults will become unaffordable next year if Congress doesn’t gut an important consumer protection in the reform law.

In 2009, shortly before the Senate voted on reform, America’s Health Insurance Plans —the main industry trade group —hired PricewaterhouseCoopers to estimate how much premiums would increase under the law. The study was quickly discredited, however, when it became clear that the accounting firm had ignored sections of the legislation that would keep coverage more affordable.

The current study, by the actuarial firm Oliver Wyman, also suffers from sins of omission —which raises concerns that this new effort may also have been influenced by the insurance industry. (Oliver Wyman has not responded to my request for comment.)

Even if it didn’t finance the study, which was published last week in the trade publication Contingencies, AHIP is using it as part of its campaign to persuade Congress to delay or repeal a provision of the reform law. That provision, which takes effect Jan. 1, 2014,  will prohibit insurers from charging older people more than three times as much as younger people.

A leading Republican in the Texas legislature, who says she’s outraged by allegations that corporate dental chains put profits ahead of patients, has introduced a bill that would allow the state to regulate chains and forbid them from forcing dentists to meet revenue quotas.

A joint investigation by the Center for Public Integrity and PBS Frontline last summer found that two of the largest dental chains owned by private-equity firms, Aspen Dental Management and Kool Smiles, put pressure on its dentists to meet production goals, prompting complaints of overbilling and unnecessary treatments.

Both companies deny this. And a coalition of dental chains in Texas contends that their dentists have total control over patient care. But the chief sponsor of the bill remains skeptical.

“Several reports, including the Frontline program, have uncovered outrageous activities involving the illegal enticement of patients, especially among our Medicaid providers and often involving dental service organizations,” said Republican Sen. Jane Nelson, who chairs the Senate’s Health & Human Services committee.

Nelson did not name a specific chain. Aspen Dental does not accept Medicaid and has no offices in Texas. But Kool Smiles has clinics throughout Texas, and public records show that the state Attorney General has been investigating Kool Smiles for Medicaid fraud.

Texas has been embroiled in a Medicaid fraud scandal for the past couple of years. The initial focus was on overbilling Medicaid for unnecessary braces on children. But the scandal has since widened. State authorities said last October that beyond braces, they’ve identified 89 dental providers they suspect of overbilling Medicaid by $154 million.

You probably missed it because of the media’s focus on the fiscal cliff, but a provision of ObamaCare took effect on January 1 that can help you avoid making costly mistakes when you sign up for health insurance. At the very least you’ll be able to understand what you’re actually signing up for.

From now on, health insurers will have to provide us with information in plain English, and in no more than four pages, about what their policies cover and how much we’ll have to pay out of our own pockets when we get sick. And they’ll have to provide it in a standard format that will enable us to make apples-to-apples comparisons among health plans. Click here to see an example of what the plan descriptions must now look like.  

As you can imagine, insurers fought hard to kill that part of the law. That’s because they’ve profited for years by using legalese and gobbledygook in describing their policies, and also by purposely withholding information we really need to make informed coverage decisions. 

Now, at long last, thanks to ObamaCare, you can say goodbye and good riddance to “explanations” like this one:

“Benefits are payable for Covered Medical Expenses (see ``Definitions'') less any Deductible incurred by or for a Covered Person for loss due to Injury or Sickness subject to: (a) the Maximum Benefit for all services; (b) the maximum amount for specific services; both as set forth in the Schedule of Benefits; and (c) any coinsurance amount set forth in the Schedule of Benefits or any endorsement hereto. The total payable for all Covered Medical Expenses shall never exceed the Maximum Benefit stated in the Schedule of Benefits. Read the ``Definitions'' section and the ``Exclusions and Limitations'' section carefully.”

The Sri Lankan government is vowing to impose tighter controls on pesticides and fertilizers amid growing concern the chemicals are helping fuel a mysterious epidemic of chronic kidney disease devastating its north central region.

In September, in Mystery in the Fields, the Center for Public Integrity explored how a rare form of chronic kidney disease is killing agricultural workers in Sri Lanka, India and Central America. Scientists in each region are struggling to identify the cause of these parallel epidemics, which have led to tens of thousands of deaths worldwide and are suspected to be linked to a toxic exposure.

In a November 2012 speech laying out a national budget proposal, Sri Lankan President Mahinda Rajapaksa pledged to take action to crack down on contaminated agrochemicals.

“There is a theory that pesticides and chemical fertilizer contribute to increase non-communicable diseases,” Rajapaksa said, referring in oblique terms to the politically controversial kidney epidemic. “Therefore, regulations will be formulated to require suppliers and distributors of all agrochemicals to comply with quality standards.”

A committee of government ministers is meeting with scientific experts and interest groups and will submit a report to the cabinet with recommendations for the regulations, said Sri Lanka’s Registrar of Pesticides, Dr. Anura Wijesekera. 

Wijesekara, whose office oversees imports and permitting of agrochemicals, said Sri Lanka had already taken a significant step earlier this year: establishing limits of detection for nine toxins including cadmium and arsenic. Pesticides and fertilizers containing more than the permitted amounts of these chemicals are prohibited from distribution.

One of the most ill-advised promises President Obama made during the health care reform debate was this: “If you like your health care plan, you can keep your health care plan.”

He should have known better. First, insurance companies and employers are far more in control of determining whether or not you can keep your health plan than the government. That was true before ObamaCare was passed, and it’s true today.

Second, ObamaCare will indeed mean that some health plans will no longer be available a year from now. That’s a good thing, despite what you’ll be hearing from companies that make huge profits selling inadequate coverage.

A few insurers have for years used slick brochures and sales pitches to persuade people to buy policies that will not come close to shielding them from financial ruin if they get sick or injured.  Many people who have bought these policies undoubtedly believe they have a health plan worth keeping, especially since premiums for inadequate coverage are usually lower than premiums for real insurance. You can be certain that many of those folks will complain loudly when junk health insurance is banned in 2014 and, in so doing, become unwitting soldiers in the insurance industry’s ongoing battle to gut the consumer protections in ObamaCare.

Back to that first point for a moment. I remember shaking my head when I first heard the President assure me back in 2009 that I could keep my plan if I liked it. To deliver on that promise, the law would have to require employers and insurers to keep offering plans they want to get rid of, and that was never going to happen. A few years before I left my job in the insurance industry I was forced out of a plan I liked—a PPO—because my employer decided to stop offering PPOs to its workers and to move all of us into a high-deductible plan.

After Vermont hospitals started buying up the medical practices of local physicians, state Sen. Kevin Mullin of Rutland, began hearing complaints that prices some patients were paying for routine medical care had soared.

One family accustomed to paying about $120 in out-of-pocket costs for doctor visits and other medical services was outraged when they ended up forking over more than $1,000 for similar visits, Mullin said, mostly for seeing doctors whose practices had been bought out by a local hospital.

 “The only thing that was different was the office was [now] hospital-owned,” said Mullin, a Republican. “All of a sudden everything was charged differently.”

The root of these increases are controversial charges known as “facility fees,” and they are routinely tacked on to patients’ bills not just for services actually provided in hospitals, but also by outpatient care centers and doctors’ offices simply because they’ve been purchased by hospital-based health care systems. Hospitals argue they can’t afford to keep the doors open without facility fees.

Hospitals have billed them at least since 2000 when Medicare set billing standards for doctors employed by hospitals, and private insurers went along. Since then, the fees have grown increasingly common, costly and controversial. Critics argue that the billing practice needlessly adds billions of dollars to the nation’s ballooning health care costs and needs to be revamped. Some private insurers have protested the fees and in some cases even refused to pay them, which can add to the patient’s share of the bill. But getting rid of the charges — or even requiring medical offices to post facility fees — has proved daunting, reformers say.

Over the past couple of years I’ve met many people who, as my mother would suggest, were wishing their life away. But I quickly understood why.

These were folks in their early 60s—and even some in their 50s—who couldn’t wait until they turned 65. They were literally counting the days until they could enroll in Medicare.

Many of these folks had been uninsured for years because of pre-existing conditions.  They’d been blackballed by insurance companies andcouldn’t buy a policy at any price because they’d been sick in the past. Others were underinsured because they simply couldn’t afford decent coverage. Policies that would better meet their needs were being sold to younger people for $300 a month or less. But for them: at least $1,500.

And even the people with coverage were sick and tired of fighting to get medical bills paid and doctor-ordered treatments approved.

I’m betting every member of Congress has heard these same stories. How, then, could any of them even give the idea of raising the Medicare eligibility age a moment’s thought?

Not only would such a thing be cruel, it doesn’t make sense from an economic point of view. If lawmakers take the time to consider the facts, this idea will quickly fall off the table during the fiscal cliff discussions.