A former health insurance insider is speaking out against industry practices he calls “outrageous,” shedding light on the challenges patients face with coverage and billing. His revelations come as experts weigh in on how consumers can navigate insurance hurdles, while industry representatives respond to the growing criticism.
Patients Frustrated by Insurance Coverage
For Dave Cunningham, a 60-year-old Norton resident, dealing with health insurance has been a source of ongoing frustration. Struggling with digestive issues, he described his experience purchasing insurance through the Affordable Care Act, also known as the ObamaCare Marketplace, as deeply disappointing.
“I was told I was buying one product, and when I went to use it, I had another, and it was very subpar,” Cunningham said. With 139 different plans to choose from, each with varying premiums, co-pays, and deductibles, he found the process confusing. But what frustrated him most was realizing the coverage he had purchased did not meet his needs. “Why? Just to confuse it, to muddy the waters?” he questioned. “To make money, it’s got to be to make money. There’s got to be money at the end of the rainbow. That’s what’s going on.”
Insider Speaks Out
Wendell Potter, a former health insurance executive, echoed Cunningham’s concerns, explaining that profit remains the driving force behind many industry decisions. “Reward their shareholders. That is what is most important to these companies,” said Potter, who previously worked on public relations and lobbying campaigns aimed at blocking legislation that could impact corporate profits.
After leaving the industry, Potter turned whistleblower, writing extensively on the issue and testifying before Congress about how insurance practices have left more people uninsured or denied critical medical procedures, sometimes with life-or-death consequences. “That is outrageous, and we have allowed that to continue to be our reality,” Cunningham said.
While he acknowledges insurance companies play a significant role in these issues, he believes responsibility extends beyond them. “Our employer has not been watching this enough…I think they’re complicit in this,” Cunningham stated. “As are policy makers in Washington and state capitals.”
Loopholes and Industry Tactics
Even with the passage of the Affordable Care Act, which requires insurers to spend 80-85% of patient premiums on actual care, Cunningham said companies have found ways to maintain profits.
“They’ve been buying physician practices and clinics,” he said. “And getting involved in the pharmacy business in ways that they are now getting more money from pharmaceuticals than, in many cases, drugmakers. It’s just been ridiculous what they’ve been able to do.”
Advocates Offer Advice
Caitlin Donovan, a representative from the Patient Advocate Foundation, an organization that assists patients with medical case management, acknowledged the growing frustration. “We hear a lot of frustration, and frankly, it’s been getting worse annually,” she stated.
She emphasized that most consumers aren’t looking for a “free ride,” but rather, reliable coverage for the premiums they pay. “They just want to be assured that if they’re paying for health insurance, that in return, they’re receiving coverage. And that they don’t have to jump through hoops to get it,” Donovan explained.
For those facing insurance disputes, Donovan offered practical advice—don’t immediately pay the first bill. “Assume that any medical bill that you get has a mistake in it. We see about half of them do,” she noted. Instead, she urged patients to review their Explanation of Benefits closely and to always file an appeal if coverage is denied.
“Almost 50% of the appeals that we go through get overturned. So, it is really worth your time to go through the process,” she advised.
A System in Crisis
Donovan warned that the obstacles placed in front of patients have broader consequences, fueling distrust not just in insurance companies but in the healthcare system as a whole. “Patients dealing with these types of barriers all the time leads to distrust—not only of the insurance companies but with the medical system overall,” she said.
For Cunningham, that distrust has turned into resignation. “I think maybe my best option is to wait until something snaps or breaks and hope it doesn’t kill me before I get to the hospital to get it fixed,” he admitted.
Reporters also asked for an on-camera interview with AHIP, a national association representing companies in the health insurance industry. Rather than do this, it chose to send a statement saying:
“In the fragmented and heavily regulated health care system, health plans, providers and drugmakers share a responsibility to make high-quality care as affordable as possible and easier to navigate for the people we collectively serve. Health plans are working to protect patients from the full impact of rising costs while connecting them to care that is safe, evidence-based and coordinated.” – AHIP
With the healthcare system remaining complex and filled with administrative challenges, advocates continue to push for transparency and better protections for consumers. Resources to help inform people can be found here: Patient Advocate Foundation.