Private Health Insurance Is Not the Answer

Healthcare reform is in the air.

Ideas for dealing with the 46 million Americans without medical insurance seem to be popping up faster than new cases of the winter flu. President Bush proposes to use tax deductions to help people buy individual plans. California Governor Arnold Schwarzenegger wants to make it mandatory for everyone in his state to obtain insurance and would force employers who don't provide coverage to pay into a fund.

Democratic Presidential candidate John Edwards would raise taxes on the affluent to pay for subsidies to help those with low incomes obtain policies. Some members of Congress are promoting insurance purchasing pools for small businesses. An odd bedfellows coalition including the Business Roundtable, AARP, the Service Employees International Union and Wal-Mart is pushing for some kind of expansion of coverage but is not saying what form it should take.

What these varied plans have in common is the assumption that, at least for the foreseeable future, most of the working population (and their dependents) will continue to receive coverage through private insurance carriers. Public officials across the political spectrum are, in effect, seeking to expand the customer base for a highly profitable industry.

Surely, it is a good thing to provide coverage to the uninsured, but it is remarkable that almost everyone assumes that coverage has to come from for-profit (or, in some cases, private non-profit) providers. Despite the overwhelming evidence from other industrial countries -- and even domestic programs such as Medicare -- that government-run health plans are much more efficient, the U.S. political class seems to be on a mission to save private insurance.

A Paternalistic Reform?

To understand the current debate, it is helpful to recall some of the tortured history of health insurance in the United States. In the late 19th Century European countries began adopting government-funded social insurance plans, but the U.S. failed to follow suit. When progressives made a push in the 1910s there was opposition not only from corporate interests but also from organized labor. AFL President Samuel Gompers denounced national health insurance as a paternalistic reform, fearing that its adoption would weaken the role of unions in improving the living conditions of workers.

Consequently, Americans both rich and poor continued to pay the vast majority of medical costs out of pocket. That began to change in the 1930s. While the Roosevelt Administration focused on retirement benefits and unemployment insurance at the expense of health coverage, physicians and hospitals struggling to survive the Depression set up private group insurance plans to bolster demand for their services. The most successful of these were the non-profit multi-hospital plans that grew under the rubric of Blue Cross. These were later followed by Blue Shield plans, which covered outpatient physician services. Once the Blues paved the way, commercial insurers also entered the field, though their coverage tended to be more restricted.

After the end of World War II, there was great momentum toward expanding the portion of the population with some form of sickness insurance. In 1945 President Harry Truman proposed a national program establishing a right to medical care and protection from the "economic fears" of illness. But once again, opposition to government involvement in healthcare emerged, this time reinforced by a Cold War hysteria about "socialized medicine" stoked by groups such as the American Medical Association.

As Truman's plan went down to defeat, what grew in its place was a system of employer-provided coverage, stimulated by aggressive bargaining on the part of unions that had come to regard improving employee benefits as a mission as important as increasing wages. This put pressure on non-union employers to follow suit, and by the mid-1950s, about two-thirds of the country was getting coverage through either their own jobs or those of spouses or parents. The Blues, which held the largest share of this booming market in the early postwar period, began to fall behind the commercial carriers by the late 1950s.

Around that same time, there was growing concern about the large number of retired workers who were left out of this workplace-oriented system. This eventually led to the 1965 creation of the federal Medicare program for seniors, along with the federal-state Medicaid program for the poor, but most of those with insurance continued to get it from the private sector.

In the wake of these significant expansions of coverage, liberals renewed calls for comprehensive national health insurance. These efforts, however, were drowned out by a rising chorus of concern about escalating health costs -- a problem that was greatly exacerbated by the growth of for-profit hospital chains. During the 1980s, Congress created a cost-control system for Medicare, while growing numbers of employers transferred their workers from traditional plans into health maintenance organizations (HMOs) -- both non-profit and for-profit. The Clinton Administration tried to reach the goal of universal coverage through a complex system that preserved the role of HMOs and other private insurers, but it was crushed by business interests and the medical establishment.

Awash In cash

The failure once again to create a system of universal care left the American people at the mercy of the market. The ranks of the uninsured swelled as many employers solved their health finance problems by eliminating coverage or by shifting premium and co-payment costs to workers to such an extent that they opted out. Many of those who tried to obtain individual coverage found themselves priced out of the market or rejected because of a pre-existing condition. Those workers who retained workplace coverage increasingly had to confront HMOs and other purveyors of "managed care," whose business plan depended on restricting the use of medical services. A 1994 Wall Street Journal article stated: "Health maintenance organizations are all about penny pinching, yet they are so awash in cash that they don't know what to do with it all."

At the forefront of these service (non)providers was U.S. Healthcare, which grew out of the first for-profit HMOs in the 1970s. By the early 1990s, it was the largest publicly traded HMO, with annual revenues of more than $1 billion. The company -- a notorious proponent of gag clauses in physician contracts that prevented doctors from giving patients a thorough description of their treatment options -- took on the mission of revolutionizing the insurance industry. In a 1992 interview with Business Week , U.S. Healthcare founder and chairman Leonard Abramson expressed scorn for traditional carriers, calling them "dinosaurs" and saying they operated in "a dying world."

Four years later, U.S. Healthcare agreed to be acquired by one of those dinosaurs, Aetna Inc., for $9 billion. It was clear from the start that Aetna was going to be adopting the style of U.S. Healthcare and not vice versa. "Strong forms of managed care, gated managed care, is really coming into its own," said Aetna chief executive Ronald Compton, who also announced that Abramson would join the board of the parent company.

Aetna's marriage with U.S. Healthcare was part of a larger consolidation of the industry and a shrinkage of the non-profit portion. Aetna itself went on to acquire healthcare operations from New York Life and Prudential Insurance, while rivals such as United Healthcare (later UnitedHealth Group) also bought various competitors to rise rapidly in the field. For-profit hospital chains such as Columbia-HCA gobbled up insurers. Even the Blues were abandoning all pretenses that their main mission was to serve the community. Some set up their own HMO subsidiaries, and by the late 1990s a bunch were preparing to take the next step: abandoning their non-profit status and becoming for-profit enterprises. A few such as Anthem Inc., formerly Blue Cross and Blue Shield of Indiana, went yet further, becoming publicly traded companies.

Meanwhile, there was a growing effort to tame HMOs through the courts. In 1999 several of the country's leading trial lawyers announced plans to bring a wave of racketeering lawsuits to pressure companies to provide better coverage. Some physician groups also sued managed-care firms over restrictions on their members. The legal assault was counting on the fact that HMOs had become the most reviled industry in the United States, but the judiciary was a harder sell.

In 2002 a federal judge in Miami hearing the consolidated cases granted class-action status to claims that managed-care plans systematically denied and delayed payments to more than 600,000 doctors, but he rejected that status on behalf of some 145 million members of the plans. Five companies ended up paying nearly $650 million in settlements with the doctors and their lawyers, while two others (including UnitedHealth) went to court and had the charges against them dismissed.

What ails private insurance

These lawsuits may have shaken the industry somewhat, but they did not put an end to the abuses that characterize managed care. Here are some of the key remaining issues that surround the business:

Consolidation has continued unabated. There are now two superproviders that increasingly dominate the for-profit healthcare field. One is UnitedHealth, which capped a long series of acquisitions with the 2005 purchase of Pacificare for some $8 billion. In 2006 United's health services revenues reached an astounding $64 billion, and its medical enrollment rose to about 28 million individuals.

The other giant is Wellpoint Inc., created through the blockbuster 2004 merger of Anthem Inc. and Wellpoint Health Network, formerly Blue Cross of California. Wellpoint later spent $6.5 billion to acquire WellChoice, the publicly traded parent of New York's Empire Blue Cross Blue Shield. By 2006 Wellpoint controlled the Blues in 14 states, had some 34 million members and took in annual revenues of about $52 billion.

The second tier consists of Aetna (2006 revenues and members, respectively: $25 billion and 15 million), Humana ($21 billion and 11 million), Cigna ($16 billion and 9 million) and Health Net ($13 billion and 7 million). The non-profit wing of the industry also has big players, led by Kaiser Permanente with 8.6 million members.

There is no evidence that the consolidation has enhanced efficiency or improved the quality of coverage. Instead, the big carriers simply accumulate more power over healthcare providers and patients, using it to their own advantage.

While millions remain uninsured or underinsured, the industry's profits swell. Last year, the top six health insurance companies had combined profits of more than $10 billion. What's amazing is that they netted so much after spending prodigious amounts on marketing and administration. In 2006 Wellpoint alone burned up nearly $9 billion in such costs -- nearly one quarter of what it paid out in actual benefits. By contrast, in Canada's government-run single-payer system, administration accounts for only about 3 percent of total costs.

Legal controversies continue to plague the industry. Lawsuits over the denial of care are still being filed against the big insurers. For example, two hospitals in Queens, NY recently sued UnitedHealth, alleging a "pattern of racketeering activity." At the same time, UnitedHealth has been the subject of a federal investigation following reports last year that the company was routinely backdating stock options awarded to executives, especially long-time chief executive William McGuire, who -- on top of annual salary and bonuses totaling $10 million -- had accumulated some 29 million shares through option awards. Thanks to the backdating scheme, McGuire had racked up paper gains of more than $1 billion on those shares. In October McGuire was forced to resign and to give up an undisclosed portion of those gains.

McGuire's excesses are emblematic of the fundamental conflict in the industry -- the clash between maximizing gains for executives and shareholders, and the need of its customers for services that are often a matter of life and death. Public officials should abandon the mission of saving commercial insurance and devote themselves instead to creating a healthcare system that substitutes the public interest for private profit.