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A few more comments about health insurers:
First of all, the idea of picking patients for health care coverage based on their risk of getting sick, and refusing to cover those who have higher risk is an idea that the "managed care" companies thought up about 15 years ago to make the industry more profitable. It is unethical and wrong. The idea of providing health insurance to large groups is to spread the risk over a big enough group that the company can make a reasonable prediction what it is going to cost them, and charge a fair fee to the group. This ended when the non profit restrictions on these companies were lifted, they became large public companies, and had nothing but CEO and shareholder profit as their goal. Picking only healthy patients for health insurance and rejecting anyone who is overweight or has higher risk of disease is called "cherry picking". It is illegal in many states. In New Jersey as long as you have continuous coverage, an insurer cannot refuse you for a "preexisting condition".
If Healthnet was allowed to do whatever they wanted, they would exclude every person with any disease from coverage, and only collect money from healthy people. These companies have perverted the concept of health insurance to the ultimate degree.
Now let me focus on health care fraud. This is a big fraud indeed.. the fraud is the concept that it is prevalent, and that it is carried out by health care providers. The true fraud is insurers trying to make patients believe that they have any interest in their health. They do not. The Healthnet story is just a small example... workers told to specifically find records of patients that are costing them money and find some excuse to refuse them care. I know for a fact that before we went to electronic claims, that some insurance companies told their workers to throw claims in the garbage, and deliberately make physicians refile them before they pay anything. Aetna was just fined $9 million dollars in New Jersey for unilaterally reducing payments to out of network physicians by 40%...they just figured they would try to get away with this, and the Dept. of Banking and Insurance told them they couldn't do it and fined them. So they will just go back to their workroom and figure out some new fraudulent way to steal money.
For those of you who don't work in the system, believe me, it is much worse than you could possibly imagine. These are totally unethical money grubbing people running these companies, and they wouldn't think twice about denying payment for your care as you lay on your death bed dying of cancer because you wrote on your application that you weighed 130 pounds instead of 140. Then they give the person who discovered the error and decided to throw you out a bonus.
We have allowed these large corporations to totally take over the health care system with virtually no regulation. This occurred during the Clinton administration where Hillary's plan failed and they were emboldened to step in and use their clout to gain control of the system. They provide no value. They are not like drug companies that are actually producing a product that is valuable. They have used their market power which is completely stacked in their favor to reduce payments to hospitals and doctors, increase charges to clients, and extract most of the money for profit. This is money that should be going to healthcare and is not. William Mcguire was paid $120 million dollars when he left as CEO of United Healthcare. Horizon of New Jersey (formerly Blue Cross) is sitting on $1 billion dollars in cash. To me this is an obscenity that these companies are making profits like this and denying sick people care, so they can make more.
I am not going to go into my idea for a solution, but suffice it to say, these companies need much more oversight and regulation. Their profits, their fees, the way they deny care all need to be regulated carefully by state or federal agencies. That's the first step. I'm not sure whether a single payer system would work better. Certainly more of the money contributed would actually go to health care. I'll leave that for another discussion.
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