In Part I of this series, we discussed the shocking response some Americans had to the cold-blooded murder of United Healthcare executive Brian Thompson on the streets of New York. While most were outraged that this could happen to anyone, some actually cheered the brutal murder of a health insurance executive as if “he had it coming to him.” This raises the question why some Americans are so angered by the health insurance industry.

We learned in Part I that most Americans like their health insurance and a substantial majority give positive ratings to their health plans. But there are some problems that need to be addressed. John C. Goodman tells us in Forbes that “With one exception described below, no insurer in our health care system wants a sick person. No employer. No commercial insurer in the marketplace. No Medicaid managed care plan. And no safety net institution. Every time someone with an expensive medical problem enters one of these plans, the organization loses money. If the patient leaves the plan (for whatever reason) the plan makes money. If the plan develops a reputation for being really good at handling serious medical problems, it will attract more sick people and incur more losses. Given the horrible economic incentives that government regulation has created, the surprise is not that some patients experience mistreatment. The surprise is how few there are.”

The exception is Medicare Advantage plans. More than half of Medicare enrollees are now in private health insurance plans, called Medicare Advantage, or Part C. Like everyone else in the country they pay community-rated premiums that are independent of their health status. But unlike every one else, their premiums are topped up by Medicare, based on individual risk assessments. As a result, the total premium that the plans receive makes the healthy and the sick equally attractive from a financial point of view.

There are other advantages. The Medicare Advantage Program is the only place in our healthcare system where a doctor who discovers a change in a patient’s health status can send that information to an insurer (in this case Medicare) and receive a higher premium payment—reflecting the new expected costs of care. Accordingly, MA plans have financial incentives to discover patient problems early and solve them. These plans make money by getting patients the care they need and keeping them away from the emergency room and out of the hospital.

And, unique in our health care system are MA plans that specialize in such chronic conditions as diabetes, heart disease, cancer, etc. These MA plans actually seek to enroll patients that conventional health insurance would like to avoid. Medicare Advantage costs less than traditional Medicare and is of higher quality. Moreover, as MA presence expands in an area, medical practices begin to change – resulting in lower cost, higher-quality care for other patients.

Could the system be better? Sure. For example, United Healthcare is said to deny about one-third of its claims. But there are MA plans in Houston that have denial rates as low as 3 percent.

Goodman responds: “There are often good reasons to deny a claim. But how many are successfully appealed and how long does it take to adjudicate them? Insurance companies should be free to advertise these facts and compete on how well they take care of their enrollees after they get sick. Then, we should explore ways of making individualized risk adjustment available to the rest of the healthcare system. Economist John Cochrane believes that would happen naturally in a free market for health insurance. Maybe it’s time to give that idea a try.”

Medicare Advantage is growing in popularity, even though the Biden administration has made it more difficult for the private health insurers in the system. If you’re considering a MA plan, be sure to check with your doctors to see if they participate in the plan or you may be looking for new doctors.

 

Millions of Americans were outraged to see videos of the cold-blooded murder of United Healthcare executive Brian Thompson in New York. Yet some are actually happy to watch an insurance executive be executed and are cheering for the alleged murderer. How can we explain such behavior in a civilized society?

John C. Goodman, healthcare economist writing for Forbes, tells us a post on X wishing that the killer would never be caught racked up 95,000 likes. United Healthcare’s own bereavement message online was cruelly mocked by 77,000 laughing responses. How can people react this way?

Before we analyze what’s wrong with the American system of health insurance, let’s consider what’s right. Despite a popular misconception, a KFF (Kaiser Family Foundation) survey finds that more than two-thirds of Americans rate their health insurance as “good’ or “excellent.” And that holds for all kinds of insurance: employer plans, (Obamacare) marketplace plans, Medicare and even Medicaid.

Even among people who say they are not in good health (and who, presumably, need medical care), a substantial majority give positive ratings to their health plans. The KFF survey’s other two descriptive options for health insurance are “fair” and “poor.” Yet only a tiny percent of the public gives their health insurance the bottom rank of “poor.” That includes only 5% of people with health problems.

Goodman tells us in general, people view health insurance as different from other types of insurance, and that perception is accurate. You can see evidence of that difference by merely looking at the advertisements that appear on television and in print. In a free market, all sellers of goods and services know that the key to making a sale is to convince potential customers you can meet their needs. In fact, meeting a buyer’s needs is usually a more important selling point than the price. Casualty insurers, for example, sell their products by emphasizing the risks of bad things happening and assuring potential customers that their insurance is ideal protection.

In a free market you make money by finding people who have problems and meeting their needs. In that sense, the casualty insurance market is just like any other market. By contrast, when is the last time you saw a health insurance ad that says you will be “in good hands” if you get cancer, or heart disease, or if you need a hip or knee replacement? I bet you haven’t.

There is a reason for that. Under federal law, health insurers are not allowed to make a profit by meeting the needs of people with medical problems. In fact, they are required to charge the same premium to otherwise similar enrollees—regardless of their medical problems.

Goodman tells us the brutal reality this creates: “With one exception described below, no insurer in our health care system wants a sick person. No employer. No commercial insurer in the marketplace. No Medicaid managed care plan. And no safety net institution. Every time someone with an expensive medical problem enters one of these plans, the organization loses money. If the patient leaves the plan (for whatever reason) the plan makes money. If the plan develops a reputation for being really good at handling serious medical problems, it will attract more sick people and incur more losses. Given the horrible economic incentives that government regulation has created, the surprise is not that some patients experience mistreatment. The surprise is how few there are.”

What can be done about this situation? Is there a better way?

(For more on this subject, tune in next time for Part II.)

 

How accurate are your blood pressure readings? If you’re taking your own blood pressure at home, or even if you only have it taken at your doctor’s office, there are several mistakes that can be made that will give inaccurate readings. Inaccurate readings may lead to too much blood pressure medication, or too little. Either way your health is compromised, so getting an accurate blood pressure reading is very important.

Sheramy Tsai, writing for The Epoch Times, tells us a 2021 study in the American Journal of Preventive Cardiology suggest that we should be wary of trusting the quick blood pressure checks at the doctor’s office. Only one in five cardiologists—excluding preventive cardiologists, who manage heart disease risk factors before they worsen—follow the recommended guidelines for taking blood pressure despite having confidence in their technique.

A 2019 position statement from the Lancet Commission on Hypertension Group echoed these concerns, revealing that inaccurate blood pressure readings lead to mismanagement in 20 to 45 percent of cases in clinical settings. This is often caused by outdated techniques or limited training. Even a 5-point error can shift a reading into the hypertensive range, potentially affecting up to 84 million people worldwide.

The problem may be due to medical staff rushing in a busy doctor’s office. Or it may be due to poor training of medical technicians or support staff, who may receive less formal training than nurses or doctors. But it may also be due to patients using home cuffs without complete education. This may lead to overdiagnosis and unnecessary medication.

The study identified 5 causes of inaccurate blood pressure readings:

Causes of Inaccurate Blood Pressure Readings

1. Wrong Arm Position

Where you place your arm during a blood pressure check can make a big difference between a normal reading and a hypertension diagnosis, according to a recent Johns Hopkins study published in JAMA Internal Medicine. Using electronic blood pressure readings, researchers tested three common arm positions—supported at heart level, resting on the lap, and hanging unsupported—and found significant discrepancies in readings. The researchers found that when the arm rests on the lap, systolic and diastolic readings (the first and second numbers, respectively, in a blood pressure reading) can be nearly 4 mm Hg higher than the recommended position of being supported at heart level. An unsupported arm at the side led to even greater increases.

2. Wrong Cuff Size

One of the simplest factors in blood pressure measurement that is often overlooked is cuff size. For an accurate reading, the cuff must correctly fit the patient’s arm. A cuff that’s too small can overestimate blood pressure, while one that’s too large may underestimate it. The association recommends the inflatable part of a blood pressure cuff, called the bladder, wrap around at least 80 percent of your upper arm. Even if the cuff looks like it fits, the bladder inside might be too small or too big. Studies show incorrect sizes are often used in clinics—particularly for patients with larger or more muscular arms.

A 2023 study published in JAMA Internal Medicine highlights the issue. It found that using a regular-sized cuff on patients needing a larger one led to inflated readings—by nearly 5 mm Hg for a patient needing a large cuff and as much as 19.5 mm Hg for one who needs an extra-large cuff.

3. Crossing the Legs

Crossing your legs during a blood pressure check may seem minor, but research shows that it can significantly change the reading. A study in the Journal of Hypertension found that when participants crossed one ankle over the knee, their systolic blood pressure rose by an average of 11.4 mm Hg, and diastolic pressure increased by 3.8 mm Hg, compared with readings with feet flat on the floor.

This leg position affects blood pressure because it increases cardiac output—the volume of blood the heart pumps each minute. With more blood flowing, pressure in the arteries rises. However, because peripheral resistance, or the natural resistance in blood vessels, doesn’t adjust to offset this increase, the overall blood pressure spikes. Crossing the legs at the ankles doesn’t have the same effect on readings.

4. Full Bladder

It turns out that needing a bathroom break can do more than just make you uncomfortable—it can also raise your blood pressure. Researchers found that middle-aged women holding a full bladder showed an average increase of 4.2 mm Hg in systolic blood pressure and 2.8 mm Hg in diastolic pressure compared with after they’d relieved themselves. The effect was most noticeable after three hours, though the increase didn’t continue to rise with longer durations. This suggests that although a full bladder can temporarily boost blood pressure, it’s the discomfort and tension, rather than time, that has the biggest effect.

5. White Coat Hypertension

For up to a third of patients, simply visiting the doctor’s office can spike blood pressure readings—a phenomenon known as white coat hypertension. This temporary increase, often caused by anxiety, can elevate systolic readings by as much as 20 mm Hg. Dr. Evan Levine, a cardiologist and health care author, manages white coat hypertension by giving patients time to relax and repeating measurements. Studies support this approach, showing that allowing time between readings can reduce anxiety-related spikes. Levine often takes a second reading after the exam, allowing patients to settle down and ensuring more accurate results.

 

This last cause is one I can certainly identify with, even as a doctor myself. This highlights the importance of taking your own blood pressure at home regularly where you are relaxed and can repeat the test often for more accuracy.