Editor`s Opinion: The Rituals of Fall

In the United States, the annual health insurance open enrollment period and premium/copayment increases are as predictable as the arrival of Fall. Although the rate of health insurance premium increases has leveled off since the implementation of the Patient Protection and Affordability Care Act (PPACA), individuals and employers continue to be burdened by a system that consumes a record-setting 17% of the Gross Domestic Product (GDP).¹It can be argued that the “patient protection” component of the PPACA has been a lot more successful than the “affordable care” component. The health insurance exchange and new laws that, among other actions, forbid insurance companies from denying coverage for pre-existing or mental health conditions, retroactively canceling policies when someone becomes ill, or doubling insurance premiums because a health condition develops or may develop, have been a godsend for millions of people. For the first time ever, all Americans — not just those covered by group plans — are able to compare health insurance plans and obtain coverage regardless of age, gender, or pre-existing health condition. As of March of this year, 11.7 million people were enrolled in the state and federal health insurance exchange and the percentage of uninsured people declined from 20.3% to 13.2 %.² This is good news for persons who were unable to obtain health insurance in the past. This also is good news for hospitals; reports show, especially in states that have expanded their Medicaid program, the aggregate of charity care, uninsured discounts and provision of doubtful hospital accounts continues to drop.³

Notwithstanding reports of doom-and-gloom about the costs of enrolling people who did not receive regular care in the past, the overall health insurance industry numbers also look quite healthy. For example, Aetna®, one of the large insurance companies, announced 2013 was a record year in terms of medical membership (2.2 million), health care revenue ($44.3 billion), and, most importantly, operating earnings ($2.1 billion).⁴ Likewise, United Health Group added 1.6 million members in 2014 and from January 1 through March 31, 2015 they reported earnings (not revenue!) of $2.6 billion.⁵ This summer, Aetna bought Humana Health Care for $37 billion (and paid cash).⁶ Other insurers are also talking about merging. Highmark, a licensee of the Blue Cross Blue Shield Association in Pennsylvania, reported solid 2014 earnings and a business poised for growth, with $6.5 billion in cash and investments and $5.4 billion in surplus.⁷

These numbers are very nice for company CEOs and shareholders of publicly held companies. However, it is important to remember these are healthcare costs that yield no patient care benefits. Case-in-point: in 2012, billing-related and insurance-related costs totaled approximately $471 billion.⁸ Citing this and other studies, provider groups, some lawmakers, and 10 million Americans who signed a petition continue to push for a single-payer, so-called Medicare-for-all system to reduce health care administration and health care costs.⁹

Every year since 2003 (!), a member of the US House of Representatives has introduced legislation to provide comprehensive health insurance coverage for all US residents utilizing the Medicare model already in place, in large part because it is known to cost less to administer than for-profit and not-for-profit insurance company plans. On February 4, 2015 Representative John Conyers (D-MI) introduced the most recent act to expand Medicare.¹⁰ The chances of this bill going anywhere are very, very slim but it does make one wonder: How can the affordability component of the PPACA start living up to its expectations for individuals and employers? Is there a middle ground between an insurance industry-driven and a Medicare-driven model? I for one would love to have a choice between obtaining my health insurance from a company or from Medicare. Why can’t Medicare be included as an option in the Health Care Exchange? Adding a few more people to the 50 million they already cover should not be a big deal — no mandate, no pressure, simply one more choice on the menu. Best of all, considering the numbers reported by the insurance industry, chances are if even a small percentage of the current 11 million exchange enrollees chose to buy their health insurance from the Centers for Medicare and Medicaid Services (CMS), the long-term solvency picture of the Medicare program would look a lot better in just a few years.

If insurance companies can make a profit in the exchange, why not let CMS make some money for all of us? Who knows? We might see the day when insurance premiums and tree leaves fall at the same time! 

This article was not subject to the Ostomy Wound Management peer-review process.