Most Americans rely on some form of medical insurance to give them peace of mind when facing health needs.
It is understandable why people fear for their health and financial well-being considering how expensive modern medicine has become. Medical debt is a leading cause of personal bankruptcy. Consequently, medical insurance has become for millions of patients the warm blanket we wrap around ourselves to provide peace of mind should a medical disaster arrive at our doorstep.
The truth is: sometimes health insurance can be hazardous to your health. Medical insurance should be a bridge to needed medical care for patients, not a barrier to it.
Harm No. 1: Uncovered
A recent study by the Kaiser Family Foundation reported most insured patients do not know what their health plan covers or doesn’t cover. They might know their copays and deductibles, and those with employer-provided coverage might pay attention to how much is deducted from their paycheck to cover their portion of the premium, but most do not know much more than this.
Consider annual premiums for employer-sponsored family health coverage reached $21,342 in 2020, up 4 percent from 2019, with workers on average paying $5,588 toward the cost of their coverage and employers paying the remaining $15,754 (2020 Employer Health Benefits Survey).
Now think about this: 87 percent of insured households do not satisfy their annual deductible, resulting in insured individuals paying all or part of their insurance premium and out-of-pocket for any medical care they receive.
If households do reach their deductible, insurance plans use language that reduces transparency, making it harder to know when or if a plan will cover certain medical expenses.
Harm No. 2: Untimely Care
Studies published in several major medical journals indicate a large percentage of insured patients with high-deductible health plans delay or forgo seeking timely medical care.
In one major study, 38 percent of adults with deductibles of $1,000 or more reported not filling a prescription, not getting needed specialist care, skipping a recommended test or follow-up, or having a medical problem but not visiting a doctor or clinic.
Fifty-two percent reported carrying medical debt on credit cards. If your insurance is so good, why are insured patients taking on medical debt? Why would people with “good” insurance be so hesitant to seek timely medical care?
Harm No. 3: Prior Authorization
According to a study conducted for the American Hospital Association, 62 percent of insured patients say their household experienced an insurance-related barrier to treatment over a two-year period. Many of these patients reported becoming sicker as a result.
Doctors spend a lot of time arguing with insurance companies to get authorization for evidence-based medical tests and treatments that benefit patients.
Denial decisions are based entirely on the insurance company’s own guidelines, which are mostly designed to control their costs, not to do what is best for patients. With insurers reporting record profits, it appears some of the profiteering is on the backs of patients.
Harm No. 4: Waiting in Line
In 2022, the average wait time to secure a doctor appointment was 26 days. There are two principal reasons why: a declining number of primary care doctors and closed provider networks that lock insured patients into seeing a doctor pre-selected by the insurance company.
When an insured individual calls the typical insurance-based, in-network practice that is still accepting new patients (many are not), they often encounter a phone tree that guides them through several prompts before they reach a live human being.
It is common for doctors’ offices to double- and triple-book patients for the same appointment time slot.
Since the average time patients spend with their doctor is 10-to-12 minutes, they frequently sit in the waiting room longer than they are in the exam room with their physician. Many patients give up in frustration, choosing instead to use an urgent care center or hospital ER for primary care needs.
Harm No. 5: Rx Formularies
Insurance plans have a “formulary,” which is the list of medications a particular health plan includes. As new medications become available and the patents of older ones expire, insurers tend to change their formularies.
The same thing happens when the manufacturer reduces the pharmacy benefit manager’s discounts and rebates. This often results in medications being removed from a health plan, but the patient doesn’t find out until they try to (re)fill a prescription. This can be hazardous to a patient’s health.
Harm No. 6: Specialists
The fear hurried primary care providers have of “missing something” triggers quick referrals to specialists. This practice of “defensive medicine” typically means more screening, testing, x-rays, MRIs/CTs because specialists are also afraid of missing something. When the patient is insured, the less they will complain when insurance is presumably paying—.
Harm No. 7: Poor Individual Stewardship
The concept of personal stewardship is often the elephant in the exam room. Doctors see a lot of patients with conditions that could be avoided if they took personal responsibility for their own health.
Numerous studies confirm both doctors and insured patients are less concerned about the cost of expensive medical services. Patients think they can live carelessly, expecting doctors to help them avoid the natural consequences of their carelessness, and insurance will pay for it
Until Americans discard the notion they are entitled to 100 percent pre-paid medical care, the American health care system will remain the most expensive, most over-used, and least efficient in the world.
Mark B. Blocher (mblocher@chcenters.org) is the president and CEO of Christian Healthcare Centers (CHC), a direct primary care organization based in Michigan. CHC published a version of this article in its August/September newsletter. Republished with permission.