Why health insurance may be a danger to your health

Our healthcare system is fraught with deficiencies that seem to get worse by the week. The reason is mostly due to the increasing bureaucratization and centralized regulatory control of health insurance, coupled with efforts to keep premium prices and costs down. The result is a system that is gradually decompensating.

The most recent grand reform contributing to this condition is Obamacare. Added to Medicare and Medicaid, the Obamacare innovation was to dictate coverage for all insurance, coupled with mandates that everyone be required to have coverage, and that insurers must take one and all regardless of health status. This maneuver forced companies to provide all care for all coverage with all premiums for everyone as if they were the same--even for organizations of nuns who, for instance, have no interest in contraceptive coverage. All of this initially increased the cost of health insurance and created massive market distortions in health insurance despite repeated reassurances to the contrary.

Those increased costs drove more to the Obamacare marketplace than would have otherwise. Organizations that previously provided private health insurance to their employees turned to the Obamacare Marketplace for coverage to purchase glaringly inadequate plans.

For example, some local governments opted for Obamacare policies that restricted the total amount of insulin covered at 80 units a day, assuming that that was the maximum that anyone with diabetes would ever need. That is so far from the case as to be criminal. I happen to see a patient with Obamacare coverage (through his wife, a local government employee) who has type 2 diabetes with extreme insulin resistance—80 Units total a day doesn't come close to controlling his sugars. It is as if he has no coverage.

Then there were the distortions of expanded Medicaid, a plan that may well be detrimental to health. For example, in one study, those covered had worse health and health outcomes than those with no insurance. Part of the reason for this may be that a large percentage of physicians do not see Medicaid patients because of the very low reimbursement. Another reason is the mistaken belief among doctors that Medicaid beneficiaries are the most likely to sue. Thus, Medicaid recipients are limited to seeing the worst doctors, raising the question as to whether it is better to have a bad doctor than no doctor at all. (I am reminded of the surgeons' strike in Los Angeles in 1976, wherein, due to rapidly rising malpractice insurance premiums, surgeons went on strike for just over a month, willing to do only emergency surgery, and no elective surgery. An iconoclastic epidemiologist by the name of Mendelsohn tracked mortality statistics before, during, and after the strike and showed that mortality rates declined during the strike and rose after the strike ended.)

In the COVID era, subsidies for Obamacare were greatly expanded, but recently returned to pre-COVID levels. It was predicted that this would markedly increase healthcare premiums, but it has not. Part of the reason for this is that insurers have creatively expanded their denials of coverage, locking would-be beneficiaries out of appropriate healthcare. This has been driven in no small part by large corporations telling health insurers to limit premiums. Denial of coverage appears to have become the principal means by which insurers are keeping premiums down.

This trend got a massive boost with the advent of GLP-1 analogs, FDA-approved for the treatment of obesity. This was a watershed moment in medical history due to the high and ever-rising prevalence of obesity in our society. Faced with the prospect of massive increases in costs and massive rises in premiums, large companies that pay a large share of healthcare premiums told the insurers that they would not accept the rise in premiums that coverage of GLP-1 analogs for weight loss would induce. So insurers stopped covering this FDA-approved treatment for obesity. The insurers could do this because the Centers for Medicare & Medicaid Services (CMS) refuse to acknowledge that Obesity is a chronic disease, never mind that it is the most prevalent chronic disease in the nation. (CMS policies dictate both prices and coverage that are used throughout the insurance industry, not just for Medicare, Medicaid and Federal health programs.) In this regard, CMS has no contact with reality, but the American electorate seems unbothered with that disconnect.

The consequence is a draconian increase in denials of coverage, to the point that for a person with the wrong disease, care may be completely out of pocket and increasingly unaffordable.

I see new reasons for denial of coverage every day. A patient I am seeing with primary hyperparathyroidism, with a calcium level of 11.1 ( high but not critical), happens to have some pronounced neurocognitive symptoms, with difficulty in focusing and concentrating, which have impaired her job performance. Symptoms from hypercalcemia are not directly related to the measured calcium level, so such symptoms can occur even though calcium is not dangerously elevated. To ameliorate her symptoms while awaiting surgery (Parathyroidectomy), I prescribed Cinacalcet, a calcimimetic that binds to the parathyroid cell calcium receptors and makes the parathyroid cells think the calcium is higher than it actually is. This reduces parathyroid hormone production by the overactive gland (or glands) and reduces the PTH level along with the calcium level.

Her insurance denied coverage, averring that the calcium level was not dangerously elevated. The insurer specified that the calcium level must be above 11.1 before they will cover the Cinacalcet. That sounded too convenient by half, as if it were a value pulled out of thin air simply because, in this case, it allowed the insurer to deny coverage. The patient was angry at me because the insurance company denied the coverage.

Similar denials are the norm for some of the medications I prescribe for osteoporosis, with outrageous requirements by the insurer. If I see a patient with severe osteoporosis with a fracture history that needs initial treatment with the most effective and rapid acting medications, such meds as Evenity or Tymlos, insurers will insist on Fosamax (Alendronate) taken orally once a week, or Reclast, a once a year IV infusion, cheaper bisphosphonates that have fair but mixed track records and are less effective and higher risk than anabolic treatments such as Tymlos and Evenity. This is not a rare disease state, but one of the most common medical problems. Most patients who would benefit from medical treatment don't get it.

Hepatic steatosis (fatty liver) is a common malady that the medical profession has only recently come to recognize as a serious disorder. It is a risk status for cirrhosis and hepatocellular cancer, and is becoming the most common cause of liver transplant. It is estimated that the disorder affects 80 to 100 million Americans. It is consequent to the continuously rising prevalence of obesity, but not all those who have it are obese. Standard treatment has been diet, exercise, and weight loss, which are of some but limited efficacy. There are now two medical treatments for this: One, a modified form of thyroid hormone that does not act like thyroid hormone on most of the body but retains some effect on liver cells and has been shown to reverse the fibrosis due to steatohepatitis. It is a novel and recently developed medication...and expensive. Every prescription that I have written for this for steatohepatitis has been denied by the insurer.

The other FDA-approved treatment for steatohepatitis is Wegovy, the weight loss version of Ozempic. Wegovy (Ozempic) has been shown to ameliorate steatohepatitis by a direct effect on the epithelial cells of the liver sinusoids, an effect completely unrelated to weight loss induced by Wegovy. It occurs even in patients who have no weight loss on the medication. Again, insurers routinely deny coverage. Every prescription I have written for Wegovy for steatohepatitis has been denied coverage. The number of cases comes close to 100 million, hardly a trivial number. Rather, it represents a tsunami of disease gradually developing that will completely submerge our healthcare system. Robert F. Kennedy Jr's emphasis on diet and exercise is great, but won't do much to forestall the tsunami of liver failure descending upon us. Even the great physicians who now run CMS, NIH, CDC and FDA seem unable or unwilling to change the original designation that obesity is not a chronic disease. Calling obesity a chronic disease is like saying you see a Unicorn in the Garden. You risk being accused of insanity. So don't count your boobies before they hatch.

Not infrequently, I will be told by the insurer that the patient must fail other treatments before they will be allowed to use the treatment I prescribe. This is the invariable case with Zepbound, the weight loss name for Mounjaro, a dual-acting incretin similar to Wegovy. Zepbound is FDA-approved for the treatment of Obstructive Sleep Apnea. Once again, all prescriptions I have written for this treatment have been denied by the insurer. I will be told that only after the patient has failed NCPAP management will treatment with Zepbound be allowed. This is the famous "Step approach" to disease management. One treatment must be tried and failed before the next is allowed. This is a common approach to many medications. However, in the case of Zepbound for Sleep Apnea, the whole idea that using Zepbound to treat sleep apnea is that it can actually improve the disease is sheer idiocy. NCPAP helps compensate for the effects of the disease, which is oxygen desaturation during sleep with episodes of apnea. This puts strain on the heart and vasculature, pretty much all internal organs, drives hypertension and weight gain and cardiovascular risk. So NCPAP management can ameliorate the effects of sleep apnea by preventing oxygen desaturation. However, it does not improve the disease state. Zepbound, on the other hand, improves the disease state by inducing weight loss, which lessens the oxygen desaturation. Theoretically, given enough weight loss (obstructive sleep apnea is a phenomenon generally induced by obesity), the sleep apnea can be eradicated and NCPAP management can be discontinued. So the two treatments are entirely complementary and are not to be used sequentially, but rather together. It appears that the insurers have carte blanche to ignore reality.

In short, our healthcare system is nothing of the sort. It is an anti-healthcare system. It is not working. It is structured to deny needed care, not cover it or allow access to it. To the extent that marvelous new treatments are developed, the more will obstruction to healthcare increase, obstructing improvements, indeed breakthrough modalities, to healthcare that are now growing exponentially. A bright healthcare future is being snuffed out as it is a-borning. The only solution is to scrap our government-controlled, highly regulated, too costly (and costs explode due precisely to government attempts to control them) healthcare system, including Medicare and Medicaid (I can hear the gasps from California to the New York Island). Reform measures proposed by the government are only going to increase the problem and the costs or obstruct access to healthcare altogether. The American version of rationing is denial of coverage (as opposed to the Canadian or British system of queuing). Time is of the essence. Life is short, and will become shorter and more Hobbesian the more government healthcare we get, good and hard.