The following article was originally published in the Ohio Capital Journal and published on News5Cleveland.com under a content-sharing agreement.
Their message may come as zero surprise to the vast majority of Americans. But on Wednesday, advocates, experts and practitioners said the nation’s health care system is badly broken and dramatic measures are needed to fix it.
From lifesaving drugs that have become unaffordable to disappearing neighborhood pharmacies to arbitrarily enormous out-of-pocket expenses, everybody knows somebody with a horror story about getting sick and trying to get help.
That’s because for decades, control of that system has been handed over to huge corporations that prioritize profit over making Americans as healthy, happy and productive as possible, said Nidhi Hegde, executive director of the American Economic Liberties Project, an advocacy group that studies the impact of corporate concentration on average Americans.
“Our health care system is in critical condition, and it’s core sickness is monopolies,” she said in a virtual event announcing a new initiative to break up corporate control of the system. “Today, big insurers and other corporate entities employ over three quarters of our doctors, directing how they provide care. Most metropolitan areas have just one or two healthcare systems controlling the local market, leaving patients with few choices.”
Big money, big effort
Corporations working in the health space are now seven of the 20 largest by revenue in the United States. There were none in 2000. American per-capita health spending is by farthe highest in the world, yet it produces greatly inferior outcomes. So it’s hard not to suspect that somebody’s skimming exploding amounts of money without adding much in the way of value.
To address the phenomenon, the American Economic Liberties Project on Wednesday announced a sweeping initiative — Break Up Big Medicine. It seeks to mobilize the public and policymakers to do big things to orient care toward communities and away from quarterly earnings calls.
“Just as the Glass-Steagall Act reined in big finance after (the) 1929 (stock market crash), America is in need of similar structural solutions to address the conflicts of interest that permeate the entire U.S. health care system to restore competition, reduce costs, and improve access to quality health care,” Hegde said. “The time is now and there is no middle ground.”
Morgan Harper, the Columbus-based advocacy and policy director of the economic liberties project, said that everybody has an interest in thoroughgoing health reform.
“This isn’t just a wonky, D.C.-based issue,” she said. “Health care affects all of us, and unless you’re one of the folks leading one of these large health care corporations or investing and making a ton of money, you are one of the millions of people with an interest in seeing them broken up.”
Real people
Marion Mass, a Philadelphia pediatrician, gave an example of how she thinks patient care and corporate pursuit of profit don’t mix.
A teenager started having migraines so severe that she was forced to miss 30 days of school and have three inpatient hospitalizations in a five-month period. After her docs tried several ineffective therapies, a pediatric neurologist recommended a drug that was “off label” — meaning the U.S. Food and Drug Administration hadn’t approved it for that use. It was expensive, and the pharmacy benefit manager required a “prior authorization” before insurance would pay.
The three largest pharmacy benefit managers control 80% of drug transactions on behalf of insurers and each is part of a giant conglomerate that also owns a huge health insurer. Think UnitedHealth Group, CVS Health and Cigna-Express Scripts.
They say they bring the consumer costs for drugs down. But the Federal Trade Commission last year said they appeared to be forcing prices higher and making patients sicker.
In addition to many other ways they control drug transactions, pharmacy benefit managers, or PBMs, decide which drugs are covered. When they require a prior authorization, the prescriber has to file a special appeal — a cumbersome process that Mass said harried doctors spend an average of 12 hours a week on.
Since the insurer that would have to pay for the drug is often owned by the same corporation as the PBM deciding whether to make the insurer pay, that could put a patient’s health in conflict with the corporation’s financial considerations. And for doctors, the demand that they take extra steps to prove a patient needs a drug or a treatment and it still can be denied is maddening.
Mass said that such denials often mean that doctors are “not allowed to practice medicine. They’re simply told no.”
She added, “You spend all that time (asking for prior authorization) and they still come back and say no. What’s the purpose of these insurance companies? Why do we even call them insurance companies when you are felled with a disease that you didn’t ask for, you didn’t know it was coming down the pike, you couldn’t plan for it and you’re told that it’s just not covered and what your doctor wants for you doesn’t matter.”
Fewer pharmacies, more expensive drugs
Emlah Tubuo, owner of Powell Pharmacy in Columbus, complained of PBM reimbursement practices. Not only do the three health conglomerates’ PBMs make non-transparent decisions about how to treat their own insurance companies as well as competing insurers. They also own pharmacies, and their PBMs decide without transparency how to reimburse their own and competing pharmacies.
Tubuo said her and other pharmacies are getting the short end of the stick in what she thinks are conflicted decisions.
She noted that the number of Ohio pharmacies has dropped under 2,000 for the first time in at least a decade. The losses are particularly acute in vulnerable communities, where the pharmacy isn’t just a place to get vaccines and prescriptions filled, it’s a place talk to a professional about your health.
“This is creating pharmacy deserts in underserved population areas,” Tubuo said.
PBM decisions are harming other huge groups of people, another advocate said.
Jenna Riemenschneider, vice president of the Asthma and Allergy Foundation of America, said asthma is the most common chronic illness in children and causes the most missed school days.
She described how last year one of the most common inhalers, Flovent, came off the market and was replaced by a lower-cost generic. That should have been good news for asthma sufferers, but many insurers and PBMs refused to cover it. So millions of asthmatics and their families were faced with much higher out-of-pocket costs or using medicines that were inferior, she said.
“The repercussions have been swift and significant,” Riemenschneider said.
Three million former Flovent users saw a 17.5% increase in hospitalizations, she said.
Such problems are “due to a system where insurers and PBMs are often owned by the same companies,” Riemenschneider said. “This vertical integration prioritizes profits over patient health.”
Rationing, bipartisan anger
Opponents of a European-style national health service have long warned that it would lead to the government “rationing” of health care — of deciding to let grandma die because she’s no longer of value. However, that’s effectively what’s happing now, only the decisions are being made by people who are accountable to shareholders, not voters, one expert said.
Hayden Rooke-Ley of the Economic Liberties Project said when supposedly insured people are denied care, it amounts to “corporate rationing.” And, he said, it’s not an accident.
“It’s the product of deliberate policy-making decisions and legal decisions that we’ve made over the last number of decades,” he said. “It’s a deliberate decision to… outsource our Medicare program — now half of that program, in the form of Medicare Advantage — to the nation’s largest health insurance companies. Each year we’re cutting checks worth hundreds of billions of dollars of public money to the United Healthcare’s of the world, to the Humanas of the world, to essentially ration health care in our system.”
However, anger over the present system is building across the political spectrum, said U.S. Rep. Jake Auchicloss, D-Mass. Last year, he and a bipartisan group of lawmakers almost got the most sweeping PBM reforms built into a spending bill. But then House Speaker Mike Johnson, R-La., backed down from an industry group, Auchincloss said.
But there is still a strong bipartisan consensus and now it’s time to think bigger, he said.
“Over the past 15 years (since creation of the Affordable Care Act), too much of congressional policy has been oriented toward subsidizing health insurance companies,” he said. “Now they’ve come to Congress and said, ‘We’re so smart. We have all these actuaries and we have this brilliant idea about value-based care, and if you just give us money… we’ll take care of everything else. We’ll make sure patients do everything right, we’ll take costs out of the system and we’ll put the patient first.’
“Well 15 years on, it ain’t working out so great. I can see that Unitedhealth Group is doing fabulously with their $3 billion in quarterly profit. I can see that Aetna, Cigna and the rest have been making hundreds of billions of dollars. What I’m not seeing is that patients and providers feel like they are being empowered… We have to shift away from subsidizing insurance companies and instead directly providing funding and support and resourcing to providers themselves.”
