Insurance Companies Gaming the System

By Donna Smith –

Has your insurance company called you recently to ask you to sign up for a wellness or disease management program? Has that same company told you it’s a free service to policyholders and promised you that they do not share the information with the departments and people who administer your benefits and claims? You – like me and millions of other Americans – are being scammed.

Follow the money, my friends, and do not believe for one minute that the same company that would deny medications, health treatments and care to you would suddenly have your best interests at heart. It’s the money. It’s always been the money.

As soon as the Patient Protection and Affordable Care Act (PPACA) was passed, we were all told that finally the insurance companies would have to spend more of the premium dollars they collect on actual healthcare. Look it up here for the nitty-gritty.

In short, The Kaiser Family Foundation writes, “The provision requires most insurance companies that cover individuals and small businesses to spend at least 80% of their premium dollars on health care (i.e. medical claims) and quality improvement, leaving no more than 20% for administration, marketing, and profit. Large group plans must spend at least 85 percent of premium dollars on health care. Insurers failing to meet these standards will have to pay rebates to consumers beginning later this year.”

And those rebate checks some policyholders are getting are also attributable to this provision of the Affordable Care Act. Sounds great, eh? What’s not to like about making the for-profit insurance companies spend more on actual healthcare or give us some money back?

What’s not to like is that never doubt for one instant that the for-profit insurance companies have found ways to subvert that well-intentioned – or at least well-scripted – nod to more accountability. Insurance companies like to make money – it is what they are for and what they are all about.

Health insurance is not healthcare. Health insurance is a financial product sold to you and to me to protect our health and our wealth which may well do neither thing. Health insurance companies do not exist to make you healthy but to make their stockholders wealthy. If you think otherwise, you are not understanding the fundamentals of corporate life or the laws governing what corporate CEOs are to do for their primary customers – their shareholders.

So, if required to provide more actual care that might reduce actual profits, what’s a good health insurance executive to do? Well, go to work changing what qualifies as actual healthcare under the new rules and then find ways to make even more money by providing that while denying more real healthcare services. And that’s exactly what is being done to you and to me.

Wellness and disease management programs now qualify under the ACA as part of what insurance companies can call “medical loss” for purposes of meeting the criteria required to be spent on healthcare. Having that nurse or other insurance company employee call you and me monthly and recount which medications we take and for what conditions and then set an appointment to do it again every month is considered spending on health care. That’s right.

Just last week, on the same day my insurance company, Aetna, was denying medications ordered by my doctor during the diagnostic and early care phases of my latest cancer journey, I was being absolutely dogged by the Aetna Connection folks (their wellness and disease management plan) wanting me to reconnect with the nurse who “needs” to engage with me on a monthly basis. Imagine, on one call I am begging Aetna to approve a medication needed to help me and relieve gut pain while on another call, I am telling the front person for Aetna Connection that I really don’t care about setting a new appointment with the wellness plan while Aetna is denying my care. I even told the caller I was groggy from the general anesthetic and that I couldn’t talk because of a sore throat from the intubation tube and that I hoped they’d call back another time when I could think more clearly, but she didn’t care. Like a collector of a very serious debt of some kind, she needed to get me assigned to a call date.

Imagine how many millions, if not billions, of dollars Aetna and every other insurer can now claim are being spent on healthcare through these programs. And imagine then how they will be actually able to deny real healthcare services when those millions spent on non-care figure into the totals they are required to spend on the new law.

We are screwed. At least I know I am. Aetna didn’t care for one moment if I got through this weekend in pain or was able to eat or rest comfortably. Aetna did care if I stayed in the Aetna Connection program. So, beware, fellow Americans. There is big money at stake in our healthcare system until it is changed to a more sane and honest system that values human life over cash. We need an improved and expanded Medicare for all for life system that cannot be gamed for profit.

Right now, we are still just part of the profit base for large health insurance companies and other healthcare corporations. We are not patients. Not yet. Follow the money.


  1. Anna YaLee on August 17, 2012 at 5:55 pm

    I really like this website. I understand insurance here in America is going up with new changes. In my country insurance is different, not like here in America. I thank you for the information. Here it was easy for me to understand.

    Thank You,

  2. samantha on December 20, 2012 at 4:17 am

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