Ep45 -- Unhealthy Assumptions

 There have obviously been innumerable postmortems explaining exactly why Vice President Harris lost the election.  Curiously, the vast majority of them are written by people who were spectacularly wrong leading up to the election, and for some reason expect us to believe what they have to say now. But in all fairness, they all have some element of truth to them, even if their prescriptions moving forward vary from reasonable and valid to, in my humble opinion, are you freaking serious? Are the Dems really going to once again learn exactly the wrong lesson from this loss?  But I don't really want to dig into that too deeply except to say that I think syncing up with the national vibe, while not sufficient on its own to win an election, is a necessary component of a winning campaign.  And in 2024, defending the status quo didn't really feel right. And, "our billionaires are more enlightened than your billionaires"  doesn't really offer much hope for a better, safer, less anxiety-riddled future for the vast majority of Americans. 

I'd suggest hewing a little closer to Anand Giridharadas's edict that "Billionaires are not our saviors, they're our mistake."  That kind of statement might make some people uncomfortable, but it would get people's attention and make them want to hear more about how you're going to shake things up. And it would have definitely resonated with the national vibe. 

And I think the same goes for healthcare, which for obvious reasons is at the top of many people's minds these days, though it was glaringly absent from the presidential campaign,  except of course for Trump's claim that he's going to dismantle Obamacare and provide something way better, even though he clearly has no clue what he's going to replace it with. But that kind of dramatic-shift thinking obviously resonated. 

So this week, I want to talk a little bit about healthcare, not so much to dig into the specifics about how we got here and why our system sucks so bad, although I will touch on that, but more just to loosen up our thinking around healthcare a bit and help us become more flexible and creative in our thinking about how to change it. Stay tuned. 

I'm Craig Boreth, and this is The Great Ungaslighting, a podcast about how we all get conned into accepting a manmade culture that's out of sync with our human nature, and how to fight back and put the kind back into humankind. 

But first a word about a sponsor. 

This week's episode of The Great Ungaslighting is not brought to you by, appropriately enough, Medicare Advantage.  I'm a ways away from qualifying for Medicare, so maybe some more experienced listeners will already know what I just found out, but Medicare Advantage is not Medicare.  It's sold as offering some benefits that regular Medicare doesn't like free or discounted dental hearing or vision coverage, and even things like gym memberships. Sounds pretty good,

right? 

But here's a quick primer. Regular Medicare is a government run health insurance program, meaning your doctor recommends a procedure, you have the procedure, Medicare pays the bill and that money comes from the publicly funded Medicare trust fund.  Medicare Advantage is private health insurance provided by companies like UnitedHealth and Cigna who then get reimbursed from that same Medicare trust fund.  Now, I don't know about you, but I find this really misleading. And it's supposed to be. After all, when politicians talk about privatizing Social Security and Medicare, they get hammered. Call it Medicare Advantage, add on a few tasty perks, and folks will apparently have no idea that you just privatized Medicare.  But of course, you probably have a little voice in the back of your head saying, isn't the private sector more efficient than the public sector?

Well, sure. Some reports claim that Medicare Advantage has lowered costs. But in this case, costs are payments to patients for medical procedures. And guess what, when those private insurance companies lower costs, often by rejecting claims that regular Medicare would automatically pay, do you think they're returning the unused money to the government? Of course not. They're paying exorbitant executive salaries and giving it to their shareholders in the form of massive stock buybacks. UnitedHealth alone spent $6 billion buying back their own stock in 2023. 

So, let me just give you a quick example of how insane this setup is. Remember those extra perks offered to Medicare Advantage subscribers, the dental and vision coverage. Well, they cost the government $64 billion in the past year.  But the private insurance companies administering the plans won't tell the government how much of that $64 billion actually went toward providing those perks.  I'm assuming that they just came up with the price for the perks, multiplied by the number of subscribers, and sent the government the bill.  What we do know is that only a small percent of those subscribers actually use those benefits. Only about 10% of Advantage subscribers use the dental benefit. About a third use the benefit for over-the-counter medications. And a quarter of subscribers don't use any of the additional benefits offered by Medicare Advantage at all.  So while we don't know the total, it's safe to assume that a sizeable chunk of that 64 billion, an amount certainly in the billions of dollars, was just extra money that taxpayers handed over to insurance company executives and shareholders. 

Also, just to give you a sense of how profitable Medicare Advantage and other private insurance products for seniors are to the companies that administer them.  AARP refers its members exclusively to UnitedHealth products and receives in return a 4.95% kickback.  AARP refers to these kickbacks as royalties.  As you probably know, AARP is a big powerful organization. Last year, it brought in almost $290 million in membership dues, but the royalties it collected from referring its members to private health insurers totaled $905 million.  How profitable must those plans be if the insurance companies can kick back almost a billion dollars and still make a hefty profit on top of that? 

I'll tell you one thing, Medicare Advantage sure is aptly named, of course less so for the seniors who get the advantage of better coverage, and more for the public that's being taken advantage of. 

And we're back. 

I read a couple of interesting quotes about healthcare in this past week. One was from United Health Group CEO Andrew Witty, who wrote an opinion piece in the New York Times offering some nebulous non-specific bromides about how much he really wants to improve our healthcare system.  But the truest thing he said was this,  "No one would design a system like the one we have. And no one did. It's a patchwork built over decades." Now, keep in mind that Andrew Witty made $23.5 million in 2023 and holds about $150 million worth of UnitedHealth stock. So that system is working pretty well for him and I can't imagine he would be interested in changing it in any substantive way. Which of course begs the question, why would the New York Times ask him to write an opinion piece about how he'd suggest we change the system and would expect anything other than banal platitudes?  But again, he's right. The system wasn't designed this way. It evolved over time. But I think Witty is offering up this fact as a way to say that the current system is nobody's fault. And while there's no one specific person you can point to, to blame our current system on, in general, it seems to me like the fault lies in how we Americans in particular look at healthcare and health insurance.  And it's the same way we look at a lot of things. For whatever reason, and if you read Heather McGee's book, The Sum of Us, it's really hard to say that race. Isn't definitely one of the reasons, we just can't seem to be willing to offer any public benefits to everyone.  And by the way, if you want to find out about a really disturbing part of our history that very likely still haunts our thinking about healthcare, look up Frederick Ludwig Hoffman and the idea of "scientific racism". 

Okay, so the second quote I read this week was this:  "What we are now talking about doing most of the countries in Europe did years ago. We are behind every country, pretty nearly, in Europe in this matter of medical care for our citizens." Obviously, right? We spend twice as much per capita on healthcare as most of our European peers and have worse results to show for it.  Now you might be amused, or more likely deeply saddened, to learn that that quote is from John F. Kennedy in 1962.  So we've been thinking about this for a long time and we keep spending more and more money and getting worse and worse results.  

And it seems clear to me at least that the problem is that along with so many things, for some people, America works really well. I mean a quality of life unmatched in human history and continually improving year after year. But for many, many other people, that's simply not the case. And if their lives are improving at all, they're improving more and more slowly. And for lots of people, they're actually getting worse.  For those people at the top, those with great health insurance, the healthcare system is like water to a fish, like we've talked about. You hardly even notice the behind-the-scenes machinations. Appointments get made, procedures get recommended and approved, copays are barely noticed, and the system seems to chug along smoothly.  So remember, like I talked about last time, when it comes to the American healthcare system, people seem to be living in completely different realities. We're separate groups of fish and completely different ponds. And that I think prevents us from seeing the true failure that marks our system. If you look at it politically, on one hand, you have the private health insurance advocates and on the other hand, you have single-payer or government-paid health insurance proponents.  Our system is a dizzyingly complicated mix of those and Obamacare in 2010 was it compromise that tried to allow both systems to co-exist and intermingle in a way that could allow more people to access insurance.  Remember access insurance. That was the key. Not necessarily healthcare. And definitely not health outcomes, but health insurance.  And as Dr. Aaron Carroll noted in the New York Times in 2023: "Insurance is really just about moving money around. It's the least important part of a healthcare system." And yet that's what we in America are always fighting over. Dr. Carroll sums up what really matters in three words. Universal coverage matters.  What doesn't really matter is how you get there.  And that seems to be the change in perspective that is needed. If we're going to ever truly change our system for the better, we need to start from an assumption that everyone has a fundamental right to a healthy life and a decent level of health care.  And then we might be able to rebuild the system based on that assumption.  

You think this would be easy, especially given that promoting the general welfare is one of the main reasons we espouse for forming this country in the first place. But clearly it's not. And as many times as politicians state matter-of-factly that healthcare is a human right, for any number of reasons that notion is not a fundamental belief in this country. We remain the only developed country in the world that doesn't recognize healthcare as a human right.  And I don't think we're ever going to have a healthcare system that really works for everyone until we do.  

But if we can do that, we'll find that it's relatively easy to actually implement the system.  There are functionally very different systems that work well around the world, from a regulated all private system, like Switzerland's to a single payer system, like Canada's. Do they work perfectly? No. But they start with the requirement of universal access to healthcare. And then figure out the specifics.  

Do those other systems have problems? Of course they do. They have long wait times, the increasing expense of aging populations, and expensive new technologies. But then of course, so do we, but those other countries have already figured out how to do what we can't: achieve universal access. All they need now is more money to take care of their existing problems.  

And that as Dr. Carroll points out, might actually be a cause for optimism here in America.  As he brilliantly observes, "We cannot seem to do what other countries think is easy. While we've happily decided to do what other countries think is impossible. We've already decided to spend the money. We just need to spend it better."  

Of course, in order to do that, somebody in a position of real political power is eventually going to have to piss off their billionaires.  

Well, that's it for this week. If you like this episode, please leave a review and forward it to anyone else that you think might also enjoy it. I hope everyone enjoys their holidays to the fullest, and until next time, be kind to yourself, cut each other, some slack, and use your damn turn signal.