One thing our government doesn’t like doing is challenging the greed of health insurance companies. I can speak with some authority about holes in the ever-fraying safety net of our healthcare system, including Tricare, the military health insurance plan used by most troops, veterans, and their families, other employer-sponsored health insurance, state-sponsored care like Medicare and Medicaid, and individually purchased plans. After all, I’m the spouse of a veteran who uses military healthcare and a clinical social worker. I serve military families that rely on a variety of health insurance plans to pay for their care and believe me, it’s only getting harder.
To take one example: at least in my state, Maryland, Tricare, if it pays at all, compensates clinicians like me far less for mental healthcare than Medicaid (government medical assistance for low-income Americans). It also misleads military patients by referring them to me even after Tricare has acknowledged that I’m unable to take more of them. Other healthcare plans serving Americans go months without reimbursing me for services they authorized.
Over the years, I’ve written for TomDispatch about many things that military families go through — most similar to what other Americans experience, although almost invariably a little more so. That includes the struggle to feed their families and stay out of debt, the search for childcare, a growing sense of loneliness and pain, and, of course (to mention something so many other Americans haven’t experienced) exposure to the violence of war and its weaponry.
Private companies — and not just medical ones — shape the contours of American life in so many ways, even if we don’t know those companies’ names. Take arms contractors who have contributed so much to the spillover of military-grade weaponry into the hands of civilian killers. Just as all too many Americans, including schoolchildren, have found themselves forced to stare into the barrel of an AR-15 rifle, so have distressed soldiers stared into the “barrels” of companies few of us have heard of that can decide whether they’ll ever get the opportunity for therapy.
Sadly, in my world, greed all too often shapes how we live, just as it’s shaped the world of… yes, the Supreme Court. And for that you can thank the magnates who so generously gifted lavish trips and perks to Justices Clarence Thomas and Samuel Alito while they handed down morally devastating decisions on so many issues, gun control and abortion among them, that will determine the nature of life and death in this country.
In a moment, I’ll tell you a bit about my own experiences as a clinician. But let me start by saying that, for me, as a therapist, wife, and mother, nowhere is the relationship between corporations and everyday life more impactful than in the ways our government allows health insurance companies of every kind to avoid truly paying for the care Americans need. (Ask me, for instance, whether Tricare paid for my family to get flu shots this year. I’ll bet you can guess the answer to that one.)
Americans, who are getting sicker, sadder, and ever more anxious, are so often unable to access necessities like healthcare because all too many legislators, judges and administration officials refuse to hold large companies accountable to the rule of law — when, that is, significant laws related to such corporations even exist.
An uphill battle to provide affordable mental health care
As a therapist, I accept most major insurance plans in the Washington, D.C., area, where I operate a small private practice out of my rural home. I set out to make care accessible to middle- and lower-income Americans, particularly those who fought in America’s wars, were impacted by them, or grew up in a military family — groups where suicide rates are significantly higher than in the general population and where depression, anxiety, and violence are rampant.
I have a social science PhD that has helped me figure out how complicated systems work, yet our insurance system (if it can even be called that) confounds me. I find myself turning away dozens of people every month because I can’t afford to lose more time and income dealing with the complications of their insurance.
My standard line for those who come to me seeking care is too often: “I’m so sorry, I wish I could help, but I’m unable to take any new patients with [insert here major healthcare plan, most of them state-sponsored or, in the case of Carefirst, D.C.’s version of Blue Cross Blue Shield, contracted by the federal government for its employees].” I then wonder what will happen to that suicidal three-times-deployed Afghanistan and Iraq veteran with young kids at home, who’s been referred to me by this country’s downsized, on-base healthcare system; or the single mother whose State Department job is supposed to offer her an insurance plan to help her manage the stress of aid work in combat zones; or unnerved asylum seekers from Russia, Ukraine, and so on (and on and on and on).
Meanwhile, in a separate area of my mind, I’m starting to try to lay the groundwork for a time when my own ability to support my family won’t suddenly be thwarted because one link in some part of our country’s fragile chain of companies that finance health care breaks for months on end.
The change health care outage
Most people I talk to around my affluent town aren’t aware that, in late February of this year, the U.S. healthcare system suffered a major setback: BlackCat, a ransomware group, hacked into Change Healthcare, a subsidiary of the corporate behemoth UnitedHealth Corporation, which (until recently at least) processed about 40% of the nation’s healthcare claims annually, including from therapists. For months after that, some major insurance companies lacked a clear route to receive medical claims from providers like me. They also lacked a way to transfer money from their own banks to doctors. Other claims payment systems take weeks or months to establish, because you have to make sure they’re in sync with the chain of companies you work with in healthcare (if you accept insurance). There’s your encrypted patient data system, your payment-processing system, the insurance company itself, and maybe a company you hire to help you with your billing. In short, the Change outage left many providers like me without a way to get paid for what we do.
Nationally, over these months, more than 90% of hospitals and many group practices (especially smaller ones) lost money — to the tune of somewhere between hundreds of millions of dollars and $1 billion daily. Tens of millions of dollars in insurance payments to providers were delayed indefinitely. Doctors, nurses, and therapists were forced to close their doors, cut staff, forego needed supplies such as chemotherapy drugs, for example, or stop seeing patients. A survey by the American Medical Association of 1,400 medical practices found that 80% had lost revenue, 55% had to use their own personal funds to cover practice expenses, and about a third were unable to pay staff. Eighty-five percent of those practices had to commit extra time to the revenue cycle. The only reason I was able to see patients is because I have a spouse with a job that covers some of our bills (as well as our mounting credit card debt).
I had a particularly difficult time getting the insurance companies that are supposed to cover the healthcare of our troops to cough up funds. Tricare took three months to begin paying me because the requirements of its subcontractor, Humana, Inc., to enroll with a new payment system were opaque even for my professional biller. Then, it took weeks more after they figured it out for Tricare to formally approve the new arrangement.
Johns Hopkins Family Health Plan, another insurance plan for military families sponsored by the Department of Defense, didn’t start paying me the thousands of dollars it owed me in backpay until late June. Maryland Medicaid went weeks or even months without covering services for three of my patients. (Lest anyone think this is unrelated to the way we treat our military families, note that Medicaid serves millions of troops, in addition to many other populations.) The only reason those patients of mine continued to receive care was because I volunteered to do it, a choice that a medical professional living in the largest economy on Earth shouldn’t have to make. A country of wealthy healthcare corporations enabled by the government, who let clinicians choose between volunteer work or turning sick people away is its own kind of banana republic.
Should we be surprised? Not in a for-profit healthcare system, where companies stand to gain by hoarding premiums long enough to garner yet more interest on them. Why would any of them feel compelled to fix such an outage in a timely fashion unless someone made them do it? — and no one did.
The Devil’s in the Details (and There Are So Many Details)
After the Change Healthcare outage, UnitedHealth’s CEO Andrew Witty testified before Congress for the first time in 15 years — a noteworthy (if insufficient) first step in raising public awareness and pressuring companies to improve their data security and prevent disruptions to healthcare. What I didn’t see was any significant discussion of why Americans need little-known companies like Change to begin with.
Change’s role is essentially to take the notes saying what we did that therapists and doctors like me write after we see patients and pass them on to insurance companies like Tricare/Humana, Medicaid/Optum, or D.C. Medicare (administered by the Pennsylvania-based Novitas, Inc.) in a format those payers are most likely to accept. If you ask me, were Change the character in the 1990s parody "Office Space" asked by downsizing consultants, “What would you say you do here?,” instead of responding, “I deal with the customers so the engineers don’t have to,” it might say, “I deal with the insurance companies so the providers don’t have to.” Essentially, Change takes my notes and sends them to the computer systems of insurers, which then (maybe) pay me. For a company that electronically dispatches healthcare claims from providers to payers, it’s done remarkably well. It was the most profitable of UnitedHealth’s thousands of subsidiaries and UnitedHealth was itself one of the Fortune 500’s top 25 companies in 2023.
So many cooks in the kitchen amount to confusion and lack of accountability for providers like me.
Prior to the Change outage, the reasons companies didn’t pay out to medical workers were often as arbitrary and unrelated to health care as you could imagine. UnitedHealth went months without paying me for therapy I did with several of its members because I wrote the number “11,” not “10,” on claim forms to indicate that I saw patients online. No matter that both numbers stood for the same thing. Worse yet, its representatives refused to tell me that this was the problem until government officials intervened on my behalf. Honestly, I don’t think we live in a “deep state” as much as in (and yes, I would capitalize it!) Deep Corporate America.
Deep corporations
Much is said these days by folks on the far right about the “deep state” and Donald Trump’s plans to gut it should he return to the White House in 2025. Speaking from the bowels of the healthcare industry, I’d say that what we have on our hands are many layers of companies (like those beneath Tricare, Medicaid, and Medicare) that decide whether and how to administer funds in ways too complicated and inhuman to truly explain. Consider it an irony then that, in 2022, the healthcare version of all of that was deepened by — yes! — a Trump-appointed judge who struck down a Justice Department lawsuit attempting to prevent UnitedHealth from acquiring Change.
Many failed states rot from the inside before they collapse, when people get so fed up with not having their basic needs met that they take to the streets. Maybe before something akin to another January 6th happens in America, more people should begin to question the assumption that private is better, that billionaires are the embodiment of the American dream, and that government, on principle, is not to be trusted. Instead, isn’t it time to hold the feet of government officials to the fire and begin a genuine crackdown on corporate greed in this country?
If that doesn’t happen, our healthcare system will prove to be just one disastrous layer in a genuine American house of cards. Unless our public officials begin to place our human rights and the rule of law first, count on one thing: somewhere along the line that house of cards, medical or otherwise, is headed for collapse.
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Copyright 2024 Andrea Mazzarino
