Nurse prac­ti­tion­ers and physi­cian as­sis­tants, oh my!

De­spite par­ti­san con­flict and man­dates, health­care in­surance is a life­line

Modern Healthcare - - Front Page -

We choose our homes and our cars, but not one of us chooses cancer or heart disease. Yet, health in­surance is the only prod­uct in Amer­ica for which an en­tire mar­ket­place of sell­ers re­fuses to of­fer to a con­sumer who wants to buy, has the means to buy, and is legally el­i­gi­ble to buy.

In no place is this more ap­par­ent than Illi­nois. In Illi­nois, in­di­vid­u­als are de­nied cov­er­age for any rea­son other than “race, color, re­li­gion or na­tional ori­gin” or, as those in pre-Medi­care years have learned, on grounds that are opaque if not mythic. The need for health­care of­ten forces some of our most ca­pa­ble pro­fes­sion­als to forgo tal­ent, am­bi­tion and self-em­ploy­ment in pur­suit of health in­surance for an ill de­pen­dent need­ing the guar­anty of group cov­er­age.

The en­tirely for-profit health in­surance in­dus­try in Illi­nois, in­clud­ing a mu­tual and stock com­pa­nies, is of­ten be­lied by the dul­cet tones and slick themes of mas­sive ad­ver- tis­ing cam­paigns. Health in­sur­ers an­nu­ally pay tens of mil­lions for mar­ket­ing on tele­vi­sion and ra­dio, and for spon­sor­ships of Chicago’s pro­fes­sional and col­lege sports teams. All the while, fewer fam­i­lies re­ceive cov­er­age of­fers.

Illi­nois health in­sur­ers have amassed cap­i­tal at un­prece­dented lev­els. The largest health in­surer in our state re­ported a 2010 sur­plus of $7.8 bil­lion. The top six health in­sur­ers in Illi­nois re­ported na­tional to­tals of at least $28 bil­lion in sur­plus. Sol­vency and fi­nan­cial strength have been dwarfed by cap­i­tal ac­cu­mu­la­tion.

For at least 10 years, small-and mid-size in­sur­ers have been leav­ing the Illi­nois mar­ket, or have been pur­chased by the larger in­sur­ers. A mod­er­ately com­pet­i­tive mar­ket 10 years ago is now “highly con­cen­trated,” leav­ing fam­i­lies and em­ploy­ers stranded in an in­ef­fi­cient mar­ket that of­fers less choice and higher cost.

Con­sumers pay more for less cov­er­age. Re­im­burse­ments by pay­ers to doc­tors and hos­pi­tals are less than ever. Com­mis­sions and fees paid by in­sur­ers to agents and bro­kers are less than ever.

In­sur­ers of­ten ar­gue that health­care ben­e­fit “man­dates” drive the cost of pre­mi­ums. More im­por­tant, the ir­refutable premise is that a ben­e­fit “man­date” equals health­care. It is be­yond true that health­care costs money. Pa­tients pay pre­mi­ums and need health­care.

There­fore, the es­sen­tial ques­tion is whether the cost of the man­dated health­care should be borne by the in­surer or by the pa­tient.

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