Managed Care One Issue That Has Received

Managed Care

One issue that has received a great deal of attention in recent months during the healthcare debate is the role of health insurance companies. Managed care was originally intended to lower costs within the American healthcare system to prevent overconsumption of health services that were unnecessary or of unproven value. However, the overall costs of the American healthcare system have increased rather than decreased in recent years, despite the rise of HMOs (health management organizations), as have the numbers of uninsured Americans unable to afford to buy health insurance. Many of these persons use the emergency room as their primary site of healthcare.

There is clear evidence that some Americans with high-quality health insurance are over-tested, despite the existence of HMOs. "Some research groups estimate that excessive, unnecessary testing and procedures account for as much as one-third of U.S. medical spending, which totaled more than $2 trillion in 2009 alone" (Gann 2012). However, conversely, there is also evidence that HMOs may be overly aggressive in denying treatment to patients who have faithfully paid their premiums. "California HMOs reject one out of five medical claims" (Girion 2009).

The Affordable Care Act (ACA) was designed in part to counteract some of the abuses perpetrated by health insurance companies, such as denying patients with preexisting conditions. With the ACA, however, because there will be more individuals with health insurance in the 'risk pool,' theoretically there will be less financial pressure to reject offering insurance to the uninsured. The system will become more cost effective if more patients can afford preventative medicine and stay out of emergency rooms, except when a genuine emergency arises. The benefits of the bill remain to be seen. But here is nothing more heartbreaking than to see a patient make medical decisions for financial reasons, versus for reasons directly related to his or her health. Every nurse has had the experience of seeing a patient receive a recommendation for a particular kind of treatment, only to have the patient decide against it because the patient's insurance company decided that it was not cost-effective. Some patients even shy away from seeking basic, preventative care that could save the system money in the long run because of high copays or a lack of insurance.

Film review: Sicko

Michael Moore's documentary Sicko is an entertaining but bracing look at the American healthcare system. What makes Moore's documentary so compelling is that rather than focusing on Americans who lack health insurance -- an easy target -- he demonstrates how even Americans who do have coverage lack adequate protection when they are genuinely ill. Moore portrays an America in which individuals who faithfully pay their premium are denied reimbursement when they get sick because they neglected to mention a minor yeast infection when applying for insurance. America is the only major industrialized nation in which citizens are not guaranteed healthcare, regardless of their ability to pay. Even many of the heroic responders of 9/11 have been denied coverage, which Moore dramatizes in a scene in which he takes the workers to Cuba to receive the care they cannot afford in the United States.

Moore travels abroad to England and France, nations which have state-supported healthcare to show that the idea that healthcare is rationed is grossly exaggerated in the media. While Moore might be criticized for not showing some of the problems within these systems -- no system is perfect -- it is worthy of note that Moore shows that healthcare in the U.S. is, in effect, rationed -- based on the ability of people to pay and the quality of their insurance, rather than upon their genuine health needs.