Insurance for Profits But Not Health

A close look at how health insurance denies access to care for children and youth with severe obesity reveals one thing. The system is really set up as insurance for profits – not for health. The story of Debra and Dan Tyler seeking care for one of their daughters, as reported by Ariana Eunjung Cha in the Washington Post, makes it clear.

Hyperphagia, Liver Disease, and Prediabetes

The Tylers’ daughter had signs of hyperphagia (excessive physical hunger) and metabolic disorders from an early age. Her high cholesterol required drug treatment, fatty liver disease was putting her at risk for serious health complications, and she developed prediabetes. Nothing worked to slow the deterioration of her health until her physician prescribed semaglutide in the form of Ozempic.

The Tylers saw a turnaround in their daughter’s health. She gained muscle, lost fat, and symptoms of fatty liver disease subsided. Her outlook brightened because, as her mother said, “she felt good.” She had more energy for sports and no longer felt plagued by physical food cravings.

But then, the Tylers’ health insurance changed when the employer providing it changed carriers to United Healthcare. They denied coverage and suggested cheaper drugs that made the Tylers’ daughter feel worse without improving the markers of her metabolic problems. It has been heartbreaking to see their daughter’s health slip away, as Debra Tyler, a nurse practitioner, explains:

“I understand medications can be overused and for the wrong reasons. But when we have this much proof that my daughter needs this medicine and it’s working, what’s frustrating is that an insurance claims person sitting behind a desk can just say ‘no, not approved’ because it’s more convenient or cheaper to do that.”

United Healthcare doesn’t want to talk about this and declined to comment.

Systems for Fast Claim Denials

Claim denials are great for plumping up health insurance profits. Every penny that the insurance doesn’t pay for that medicine the Tyler’s daughter needs goes straight to profits.

A new report from Pro Publica describes how insurance companies empower their medical reviewers to reject payments for claims without even looking at them. At Cigna, they do it in batches. It takes less than one second per claim. Dr. Nick van Terheyden fell victim to this capricious process and had to fight for months to have Cigna pay for a simple blood test he needed. He describes this as an eye-opening experience:

“It’s not good medicine. It’s not caring for patients. You end up asking yourself: Why would they do this if their ultimate goal is to care for the patient?

“Intellectually, I can understand it. As a physician, I can’t. To me, it feels wrong.”

Brushing Off the Health of Kids as an Unnecessary Expense

It’s very clear. This business is insurance for profits – not insurance for the health of children and youth with serious metabolic disease. Aaron Kelly is co-director of the Center for Pediatric Obesity Medicine at the University of Minnesota. This is a problem that haunts him and his staff:

“It’s so frustrating to hear stories like this. We finally have medicines that work really well and the kids that need them most can’t access them.

“This issue threatens to widen an already unacceptable health equity gap. Our most marginalized communities will be the least likely to have access to these potentially life-altering anti-obesity medications. We need to get this right.”

CEO Joe Nadglowski of the Obesity Action Coalition sees a stalemate that leaves people to suffer:

“Both pharma and the health insurance industry are letting people with obesity down. We have impressive medical advances that can greatly improve the health of people like the Tylers’ daughter, but these two industries can do nothing but squabble over pricing and profits.

“We need better coverage from health insurance, as well as responsible pricing and patient assistance programs from pharma. The current situation is unconscionable.”

Change is coming. For the sake of our health, it has to.

Click here for free access to the report from the Post and here for the ProPublica report.

The Golden Cosmic Egg Hiranyagarbha, opaque watercolor and gold on paper by Manaku / Wikipedia

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March 28, 2023