The reversal of Blue Cross’ efforts to drag doctors in as collaborators into their efforts to deny patients coverage is a welcome step. But it’s only a step, treating the symptom, not the underlying disease.
First of all, congratulations to Lisa Girion at the Los Angeles Times for her ongoing coverage of her story, and its broad reach and impact. If anything, it shows how the harsh spotlight of national media (including the network news broadcasts and significant print and electronic coverage) can make a difference. While the outrage was consistent from all sides, I was pleasantly surprised that the media prioritized this story accordingly.
Why does this story have such a powerful impact? After all, relatively few people–5% of all Californians–are subject to these shenanigans. That’s the number of people–about 2 million–who have coverage by purchasing it as an individual.
By contrast, 19 million have group coverage through their employer. Another 10 million have coverage through a public program like Medi-Cal or Medicare. (The rest–6-7 million–are uninsured.) Through group coverage, the insurers are not allowed to select who they want to cover, and who they don’t. The deal with the insurer is that they have to cover the entire group (all the workers at the employer), the healthy and the sick.
In the individual market, the individual has no market power. They are subject to be denied and discriminated by the insurer. So an individual tries to buy coverage, they are subjected to a mulitple-page questionnaire asking you to detail your health history–and any answer can be grounds for denying you coverage, for so-called “pre-existing conditions.” People fill out that questionnaire under penalty of perjury.
But what this recission scandal has revealed is that mistaken answers on that questionnaire can be used against patients–even those who have been paying premiums for months–in revoking their coverage. And Blue Cross is attempting to use their financial power over their network doctors to get them involved in this game of gothcha.
Why has this struck a chord, even though it’s a small population?
* Because everybody can imagine being in this situation. Even those with good employer-based coverage know that one day, they’ll be: between jobs, working at an employer that doesn’t provide coverage, an early retiree, a divorcee, a freelancer, self-employed, starting a new business, or otherwise not have group coverage available to them.
Given the kinds of reasons that people have been denied coverage, it seems that merely living is a “pre-existing condition.” And for most people, the idea that they won’t have access to coverage–even if they are willing to pay for it–is terrifying.
* This is a core values issue: it strikes right at the heart of the doctor-patient relationship. A doctor should be able to ask about the most sensitive questions–about medical problems, sexual history, drug use–and have the trust to get the most honest answers, in order to be able to provide the most appropriate care.
This places that trust in jeopardy, by having the patient wonder if an ailment he just remembered but forgot on the insurance company application should be withheld from his doctor. It provides a doctor a undeniable conflict of interest, between the patient’s best interest to get treated and be covered, and the rules of the insurer who provides the doctor’s income stream.
It goes to one of the greatest fears that patients have: that the care provided by doctors is being impacted by profit, rather than medical, considerations.
There will be legislation to address this issue. Some of it will be focused on the issue of recissions.
But the real question is how we can minimize or eliminate underwriting altogether, so that people are not denied for so-called “pre-existing conditions.”
* The first is to expand subsidized group coverage as much as possible–through employers, public programs, or ultimately a universal, single-payer health care system, so that insurers are not allowed to pick and choose which individuals they want to cover. They have to cover the *entire* group.
* If there has to be an individual market, it needs to be radically reformed with “guaranteed issue” and other, much stronger oversight over insurers. Clearly there need to be protections against “adverse selection,” whether through an individual mandate or other mechanisms, but without guaranteed issue as a starting point, then the individual market is just hopelessly broken.
The health reform that stalled in the California Senate, AB x1 1, would have *both* expanded group coverage, shrunk the individual market, and put those new “guaranteed issue” rules in place. So would the outlines of the Clinton and Obama health reform plans. SB840, pending in the California Assembly but the financing blocked by legislative Republicans, would create one big statewide group insurance pool, and would also address this issue.
As for Senator McCain, his health plan actually wants more consumers to rely on the individual market, and to do away with state consumer protections by allowing insurers to sell across state lines.
This issue of Blue Cross’ letters–it’s a small story that went big, because it goes to the very heart of the health care debate in this country. Blue Cross’ reversal doesn’t end the debate… at the national level, it may have helped jump-start it.