Heath care anger: Warranted or not?

I was going to ignore the murder of Brian Thompson, the chief executive of UnitedHealthcare, the country’s largest health insurer. However, that event has really hit a nerve with a lot of people. As usual, social media leads the way in expressing callous vulgarity and the underlying anger, e.g., one X user posted regarding feelings about the murdered CEO: Empathy: Denied! 

A lot of people are really angry at health care insurance companies and how they do business.

A NYT opinion by a doctor in a hospital seems to capture the basis for public anger about as well as it can be succinctly expressed. The doctor, Helen Ouyang is an emergency physician and an associate professor at Columbia University. Dr. Ouyang writes (not paywalled):

I rushed around the patient as he lay motionless with his eyes closed in the emergency room. He was pale and sweaty, his T-shirt stained with vomit. You didn’t have to be a health-care worker to know that he was in a dire state. The beeps on the monitor told me his heart rate was dangerously slow. I told the man that he was going to be admitted to the hospital overnight.

After a pause, he beckoned me closer. His forehead furrowed with concern. I thought he would ask if he was going to be OK or if he needed surgery — questions I’m comfortable fielding. But instead he asked, “Will my insurance cover my stay?”

This is a question I can’t answer with certainty. Patients often believe that since I’m part of the health-care system, I would know. But I don’t, not as a doctor — and not even when I’m a patient myself. In the United States, health insurance is so extraordinarily complicated, with different insurers offering different plans, covering certain things and denying others (sometimes in spite of what they say initially they cover). I could never guarantee anything.

I didn’t say all this to the man, though, because I needed him to stay in the hospital and accept inpatient treatment. So instead I hedged. “You’re very sick,” I told him. “You shouldn’t worry about your insurance right now.” I should have been able to give him a better answer, under a better system.

The killing of Brian Thompson, the chief executive of UnitedHealthcare, the country’s largest health insurer, has reignited people’s contempt for their health plans. It’s unknown if Mr. Thompson’s tragic death was related to health care, and the gleeful responses have been horrifying. But that reaction, even in its objectionable vitriol, matters for how it lays bare Americans’ deep-seated anger toward health care. Around the country, anecdotes were unleashed with furor.

Among these grievances is the great unknown of whether a treatment recommended by a doctor will be covered. It’s critical for me as a physician to build trust with my patients by giving them clear answers. But the conversations we’re seeing now about health care remind me that insurance unknowns don’t just compromise the care I can deliver to my patients — they also undermine the fragile doctor-patient trust. It’s an unsustainable dynamic. 

Unsurprisingly, despite my platitudes, my patient did worry. Instead of resting on the stretcher, he and his wife began calling his insurance company. To keep him from leaving, I tried to be more persuasive, even though I didn’t know what kind of health plan he had: “I’m sure your insurance will pay. I’ll document carefully how medically necessary this admission is.” .... I said what I could to get him to stay, but I understood why he wanted to be certain. The average cost of a three-day hospital stay is $30,000. He had heard the health-insurance horror stories. Maybe he had lived through one himself.

One of my first lessons as a new attending physician in a hospital serving a working-class community was in insurance. I saw my colleagues prescribing suboptimal drugs and thought they weren’t practicing evidence-based medicine. In reality, they were doing something better — practicing patient-based medicine. When people said they couldn’t afford a medication that their insurance didn’t cover, they would prescribe an alternative, even if it wasn’t the best available option.

As a young doctor, I struggled with this. Studies show this drug is the most effective treatment, I would say. Of course, the insurer will cover it. My more seasoned colleague gently chided me that if I practiced this way, then my patients wouldn’t fill their prescriptions at all. And he was right.  

In the end, my patient in the E.R. decided to go home that day. I reiterated how sick he was. .... But I’m not sure how much he trusted me after my overconfident assurances that his insurance would pay; when he finally got through to an agent, he was told coverage would depend on the specifics of his care.

He couldn’t risk a big hospital bill right now, he told me, matter-of-factly. He promised to come back if he felt worse.

For years, the idea of private insurance for health care never felt right to me. The profit motive is always there and it cannot be deterred. Humans will be human. The profit motive is a staggeringly powerful motivator of all kinds of behavior, good, bad, ambiguous, etc. 

Consider drug prices for patented drugs in the US compared to the same drugs in most other countries. The US government rarely negotiates drug prices because for as long as the idea of negotiating prices has existed, drug industry lobbyists and "campaign contributions" (free speech) has successfully blocked negotiated pricing to protect profits, always in the name of money needed for research for better new drugs.