Are Health Insurers Writing Health Reform Regulations?

Health care reformOne of the reasons I wanted to return to journalism after a long career as an insurance company PR man was to keep an eye on the implementation of the new health reform law. Many journalists who covered the reform debate have moved on, and some consider the writing of regulations to implement the legislation boring and of little interest to the public.

But insurance company lobbyists know the media are not paying much attention. And so they are able to influence what the regulations actually look like -- and how the law will be enforced -- with little scrutiny, much less awareness.

At a January meeting of several hundred patient and consumer advocates in Washington, a top aide to Health and Human Services Secretary Kathleen Sebelius all but pleaded with those in the audience to bombard the Obama Administration with messages insisting that the law be implemented as Congress intended. Rest assured, he told them, that the insurance industry's lobbyists were relentless in their demands that the regulations be written to give them the maximum slack.

One example: a section of the law expanding the rights of consumers to appeal adverse decisions made by their health plans.

"The Affordable Care Act will help support and protect consumers and end some of the worst insurance company abuses," read an Obama administration fact sheet from last summer.

The fact sheet went on to assure us that the new rules would guarantee consumer access to both internal and external appeals processes "that are clearly defined, impartial, and designed to ensure that, when health care is needed and covered, consumers get it."

"In implementing this law, we have worked to end the worst insurance company abuses, preserve existing options and slow premium increases," an administration official said. "Through it all, protecting consumers has been -- and remains -- our top priority."

The rules, originally scheduled to go into effect July 1, 2011, were actually written by the National Association of [State] Insurance Commissioners (NAIC), which was tasked by Congress to develop several important regulations required by the law. If the law is implemented as the NAIC recommends, patients will be able to get an external appeal of a broad range of coverage denials, including denials that result from an insurer's decision to rescind, or cancel, a patient's policy -- not just denials made on the basis of "medical necessity" as determined by the insurer.

The NAIC's standards also say that insurers must provide consumers with clear information about their rights to both internal and external appeals, and that the companies must expedite the appeals process in urgent or emergency situations.

Insurers Push Back Hard; is the White House Capitulating?

Well, surprise, insurers don't like being told what to do by regulators. So they're pushing back hard. Consumer advocates who have been in meetings at the White House in recent weeks say they believe the administration is bending over backward to accommodate the insurers.

"We have reason to fear that the external appeal regs won't be very consumer friendly," said Stephen Finan, senior director of policy for the American Cancer Society Action Network.

Finan and representatives of several other consumer and patient rights organizations, including Consumers Union, the National Partnership for Women and Families and the American Diabetes Association, wrote officials in the Departments of Labor and Health and Human Services in late January pleading with them to "stand firm for consumers" in rejecting several of the insurance industry's demands.

Author Wendell Potter is the former head of PR for CIGNAThey expressed concern that the final regulations would allow insurers to stack the decks against patients by allowing health plans to deem a second-level internal appeal of a denial as meeting the requirement for an independent external appeal. They're also worried that health plans will not be required to provide clear and understandable information to policyholders about their denial decisions, that the plans will not provide adequate translation of written communications into other languages (insurers are claiming this would be too burdensome), and that they will be able to take as long as 72 hours (instead of the recommended 24) to decide an urgent appeal.

Equally as frustrating for the consumer advocates is the administration's indication that they will give the insurers until January 1, 2012, rather than July 1, 2011, to comply with the regulations.

Consumer advocates say the administration has told them that the reason it is proposing to delay the effective date of the new rules for half a year is to accommodate the health plans' enrollment cycles and marketing needs. Health plans do need adequate lead time to make changes to their systems and to prepare materials to inform their customers of new procedures, especially in multiple languages, so some of their push back is understandable. The new regulations will also add to the insurers' administrative costs, and the new law limits how much they can spend on overhead.

But the consumer groups believe the administration itself has caused some of the problems by taking so long to finalize the regulations. The NAIC got its work done comparatively swiftly.

"There is a clear pattern of leaning toward the insurance industry more than consumers," one of the patient advocates told me.

Industry Lobbyists Outnumber Consumer Advocates 100 to 1

The consumer advocates, most of whom not so long ago were applauding the Democrats for getting reform enacted, even if it fell short of their original goals, are becoming increasingly discouraged, partly because there are so many more lobbyists for the insurers than for consumers. It's hard to compete with them.

"We're outnumbered 100 to 1," said one of the consumer advocates.

It's clear," he added, "that the insurers are willing to make life more difficult for patients" by trying to weaken and delay the consumer protections.

It's also clear that, at least for now, the insurers seem to have the upper hand in dealing with the White House.


Thank you, Wendell Potter for your courage in leaving the lucrative position and advocating for the common good.

The core skills of health insurance companies are: Discrimination - Identifying which potential clients might cost them money (aka -- risk assessment). Segregation - Denying coverage for people who may become liabilities, and denying benefits for those who will not fight (aka -- risk management). The damage done to the US health care system by insurance business practices includes: 1. Coding by ICD-9 (soon to be ICD-10) blinds regulators and patients with incomprehensible detail. Adding jargon and noise to information allows those who control the medium and the messages to make money while pleading poverty. 2. Pretending that health care has "marginal benefits" that people are willing to negotiate over. Who has met someone willing to get a 50% discount to obtain 80% of the help they need to regain their health? Economics works for issues with marginal economic costs that can be negotiated, but using economics for personal health care allocation is like pushing round pegs in a square holes. 3. Many consumer health choice situations are not suitable for market based optimization. Health emergencies do not permit rational choices by consumers / clients / sick people. Rapidly spoken medical jargon reduces patient choice, without providing an effective means to overcome their knowledge deficits.

Thank you, Mr Potter. Please also address the white collar crime, racketeering and the terrorising of malpractice injured patients by medical indemnity insurers. They are literally running a protection racket. These include falsifying patients records and x-rays, thereby erasing prima facie evidence or replacing a patient's real evidence with manipulated evidence; secret insurance databases, blacklisting of patients and quite brazen battering of injured patients. The Medical Protection Society operates like this around the world, especially in places like South Africa and Hong Kong where goovernments and legislators are corrupt. The Medical Protection Society has a huge Kickback Account for bribing personal injury lawyers and judges, paying Internet hackers to read your email etc etc. We know that all these indemnity insurers act as medical defence organisations and have huge devious law firms, corrupt expert witnesses, police, health boards all colluding with them. I can help you with this if you like as I've expereinced all the above!

We also would like to add something about medical indemnity insurance companies from our family’s medical malpractice here if we might. WITH THANKS TO MR WENDELL POTTER FOR THIS We lost our father to gross negligence by staff at an Australian hospital. We did our own research on medical malpractice talked to other malpractice patients and observed the callous reactions and antagonistic responses we got from the hospital administration, medical boards and the Health Care Complaints Commission. And we learnt first hand about how a medical cover up comes about. First it starts with the Health Care Liability Bill which sets the scene for a lot of deception. Then all the major players involved- the medical boards, the medical insurers, the lawyers, the ‘experts’, and government independent commissions and what have you, all play into a very bad system for the public, who have been left with absolutely no rights or leverage of any kind. Dad’s medical records were changed and his pathology tests were too strange to be true. Abusive doctors and administrators were trying to push our buttons. They even said poor dad was an alcoholic which he wasn’t. Experts and Lawyers wanted records and money. In sum, we were subjected to a “free for all” rort by a system designed for the purpose of rorting alone. From all this we did learn from hospital staff who let stuff slip and this may be a heads up for others in the same boat we now want to help. **** ALL information you give to medical boards, associations, commissions, lawyers, hospitals, doctors, nurses, experts, anybody - they are all like vultures for any information they can get about you… is given to the 5 medical insurance companies - Avant Mutual Group, Invivo Medical, MDA [Medical Defence Assoctn] National, MIPS [Medical Indemnity Protection Society ] and MIGA [Medical Insurance Group Australia]. These insurance companies are instrumental in changing your medical records and getting any evidence from you for their solicitors to use against you. Now the sneaky bastards at these Complaints Commissions get you to sign a “permission form”, which makes the whole process very much easier for them all, This form says- “To resolve your complaint, the Commissioner requires your permission [by XX Act 2004 ]to obtain and share certain information, on a confidential basis, with the service provider and sometimes other people, for example an independent expert or a registration board. …..I understand that the Commissioner may release a copy of my complaint, health records or other personal information to the service provider or other people dealing with this complaint, and service providers may share relevant information with their professional indemnity insurers or legal advisers” We soon worked out they all work together in secret to get your information and then work out how to fiddle it all and rig pathology tests and medical records to contain information that is not true until you don’t have a malpractice case any longer! We asked the federal police if this was “Fraud” but they went out of there way not to answer and said we had to use the Complaints Commission and the Medical Board so it is a big dirty circle of collusion If you just go to the indemnity insurance company websites and read how they promise their paid-up doctors they won’t settle with patients, how doctors have to report medico-legal “incidents”, Patient Incident Reporting Forms -with the patients private details, “Risk Management” workshops, who their solicitors are, how to contact a medicolegal advisor 24 hours a day et cetra it becomes pretty clear what is going on ****and it is all about deceiving the public in a big way. You don’t stand a chance!

Get wise and check out :-:-:- " All the incentives are toward less medical care, because—the less care they give them, the more money they make." Ehrlichman: "Edgar Kaiser is running his Permanente deal for profit. " Mr. John D. Erlichman quoting Edgar Kaiser to President Nixon on February 17, 1971 " An investigation by two patient whistleblowers has uncovered Kaiser Permanente’s rigging of its electronic medical records system to conceal abnormal lab test warnings and risk explanations from 8.6 million patients in their medical records posted on Kaiser’s patient website. " As the operators of this site also state:-:-:- " The KaiserPapers is an advocacy site opposed to several medical and business practices of Kaiser Permanente. The Kaiser Papers offers personal accounts, allegations, news, links and suggestions for people to obtain information and assistance when they are navigating the health care system. Even though there are many written laws to protect the patients, the purchasers and users of health care and with actual punishments attached to them for the offenders; if the laws are never enforced they are not really laws at all. So while what Kaiser does may be illegal by the books it isn't going to do you much good at all because no one is enforcing the law. "