What A New Health Care Populism Might Actually Look Like

Hint: It's neither vigilantism nor detailed policy reform.

(Photo by Bettmann / Contributor)

In early 2021, almost a year after my first bout with COVID-19, one of my doctors (I suddenly had many) booked a short-notice appointment to measure the blood pressure in my pulmonary artery.

My spring coronavirus infection had seemed mild, but it damaged my lungs in a way that left me potentially vulnerable to heart failure and death. The purpose of the procedure was to determine the level of risk and the appropriateness of surgical intervention.

I arrived at a hospital near Georgetown University before dawn as instructed. The cardiology waiting room was locked. I sat in the lobby for over an hour, then on a hallway floor near the catheterization lab, until finally someone from the staff arrived. I returned paperwork and waited some more. A nurse called one patient who had arrived after me, then another, then another. My doctor entered the reception area midmorning, mortified. He explained to me that my insurance company had denied authorization for the procedure, but on the rushed timeline nobody had called to tell me, and the window for the appointment had closed.

I probably should have been more prepared for this news. From the moment I started asking doctors to figure out what was wrong with me—why my tolerance for physical exertion had abruptly collapsed—my insurance company had declined to authorize tests and scans as a matter of routine. The counterparty doctors who worked for Aetna would eventually back down, but only after a fight with mine.

Here again, my doctor appealed the decision and won. I rescheduled for the next available opening with the same medical group at a sister hospital across town. All in all, a survivable inconvenience.

It became clear something was amiss at the second appointment a few days later not in the waiting room, but from my gurney in the prep area, over an hour after the procedure was supposed to begin. The new interventionist eventually explained to me, again sheepishly, that while my insurance company had reversed its denial, the authorization was only valid at the first hospital.

This time I didn’t respond with as much kindness and understanding as maybe I should have, but faced with the prospect that I might walk out and never return, he agreed to perform the procedure in this pre-authorization limbo, and wrestle with the insurance company afterward.

The short of it is, my arterial pressure was OK—I did not need surgery, at least not urgently. I subsequently engaged in lengthy, adversarial correspondence with my insurance company and it’s been smooth sailing for years since. With further intervention, my physical condition improved.

But tweak the story juuust a bit here and there and it’s easy to imagine a different ending. If I’d been a little less determined, I might have foregone the procedure. If the damage to my lungs had been a touch more severe, the delay in treatment might have proved fatal. The pre-authorization denial would have loomed large. My family would’ve demanded accountability.

I don’t think they would’ve killed anybody. But to paraphrase a memorable stand-up rant from the ‘90s, I’d understand.

STAKING CLAIMS

Stories like mine and worse make it hard for many people (mostly progressive people) to believe that Americans are generally satisfied with their private health plans.

Luigi Mangiano achieved online folk-hero status for murdering the CEO of United Healthcare because of the common and basically correct belief that private health-insurance companies are parasitic. They don’t provide care to anyone, they collect money and try to spend as little as legally possible on medical services. In theory they can reduce expenditures by bargaining with doctors and hospitals, but it’s usually easier to tell patients to get bent, and many patients lack the time, resources, or sophistication to advocate for themselves.

From my insurance company’s vantage point, though, and in a world of perfect hindsight, the initial declination was correct. I was “over treated.”

I can’t say exactly what drove that decision. Presumably some kind of algorithmic exercise. My doctors had very good reason to order the procedure, but their doctors had actuarial tables. They knew my health history. They knew I was 38, with normal blood pressure, normal body weight, normal cholesterol levels… none of the classic classic heart-disease risk factors. Their process was likely little different from the one a large language model would use to determine the propriety of the referral, and if you ask ChatGPT about my specific circumstances, it says, “Insurance approval would likely depend on detailed clinical justification, including findings from the VQ scan and echocardiogram, and the rationale for excluding non-invasive tests.”

This is more or less what happened.

The denial wasn’t prescient, it was only “correct” the way someone who plays Russian roulette might snap the cylinder back into place “correctly.” My frustration, both at the time and now revisiting it, isn’t that Aetna thought I might not need further diagnostics. It’s that the opening bid to deny me care may have been warped by profit motive. Perhaps their bloodless math incorporated the statistical unlikelihood that Aetna would still be my insurer if my health were to spiral a few years down the line.

A public insurer like Medicare, whose customers don’t cycle on and off, would not have made that kind of cynical calculation. But it might have reached the same conclusion. The doctors who work for private health-insurance companies have a bottom line to consider that government payers don’t, but systems like Medicare rely on analogous professionals to make rationing decisions based on clinical and budgetary considerations.

A big part of what makes health-care politics so vexing stems from the fact that the people making those kinds of decisions are, by necessity, nameless, faceless strangers balancing competing interests and wielding power over people at their most vulnerable. When they err, or even when they make defensible-yet-frustrating decisions, it’s easy to sort them into Manichaean worldviews.

We spot this easily when Republicans do it. If Medicare had denied my claim, well that would’ve been the government getting between a patient and his doctor. When Medicare refuses to make tough calls, by contrast, that’s just more bureaucratic waste. But when private insurers make those same decisions, it’s the infallible wisdom of the free market.

Single-payer supporters, including me, are susceptible to a similar kind of reflexiveness. When Anthem cuts payments to anesthesiologists, that’s greedy insurance executives stranding patients on the operating table. When Medicare does it, that’s government purchasing power doing exactly what it’s supposed to: holding down prices so doctors and hospitals can’t vacuum up the gross domestic product of the United States.

We should be mature enough to recognize that optimal health care isn’t just the sum of procedures and prescriptions doctors might call in to treat or calm or exploit sick and anxious patients, all paid for by tax dollars. But we can also recognize that this doesn’t make Anthem and Medicare moral equals—that the biggest perverting factor in American health care, the thing that makes it worse and more expensive than elsewhere, is the profit motive. And that recognition can be the basis of a workable, pro-social form of populism, even if, at the moment, single payer is political quicksand.

People are wary of the profit motive, but their current arrangements are mostly fine. Accepting that counterintuitive fact, not ignoring it, is what actual populism entails.

THE VAGUE’S THE THING

My own frustrating experiences notwithstanding, I can see myself in everyday shoes because I could easily end up on the wrong side of a radical health-care reform.

There’s no scenario in which I’d oppose a considered legislative push for Medicare for all on ideological grounds—it would make America a better, more just place. But if enacted, my new Medicare insurance might well be less generous than the insurance I have. Now that my carrier has stopped reflexively denying authorizations, I’m like most people: basically happy with my health plan.

So were many of the million-plus people whose plans disappeared after the Affordable Care Act took effect, because they fell beneath new regulatory standards. It was, at the very least, an inconvenience for them, even though the overall policy tradeoff was clearly worth it. And it became a huge political headache for Democrats. (Google “if you like your plan, you can keep your plan,” if you don’t recall.)

All of that points to a popular sweet spot: a mix of ideas and rhetoric that’s sensitive to people’s aversion to inconvenience, but also their inclination to put people over profits.

If it wouldn’t lead inexorably to another bruising internal fight over Medicare for all, Democrats could hit that sweet spot easily. They could position themselves as enemies of the profit motive in health care—as consumer champions who will name and shame and maybe even punish bad actors in the medical system.

Doctors need to make a living, hospitals need to cover operating costs, insurance companies must pay their employees. But none of that should have to come at the expense of any patient’s interests. Aligning incentives behind actual health care might entail tightening regulations, or making insurers more like public utilities, or establishing a public option. It might mean patent and credentialing reforms to diminish pharmaceutical and physician rent-seeking. It probably means upbraiding executives at congressional hearings. It could even mean brandishing the threat of Medicare for all, if Donald Trump and the new Republican majority wreck protections for people with pre-existing conditions.

None of that would be particularly radical, but even just putting these ideas on the table in this way would make people feel like their providers were on notice.

Wonks will find this all frustratingly vague, but that’s ultimately in the nature of populism.

WARREN’S PIECE

As Democrats and the left regroup in their own ways, and if they seek a new synthesis through populism, they should each keep in mind that this is true generally: populism is not synonymous with detailed, egalitarian social-democratic politics. They may have overlapping elements, but most often they will not.

A new populism isn’t going to look like poll tested policy agendas or big, structural reforms, complete with the white-papers required to implement them. It’s going to entail pointing to things most people agree are problems, blaming those responsible (along with their Republican allies), and standing in at least a symbolic sense as a champion of change.

Donald Trump doesn’t rally the masses with carefully crafted appeals; he identifies problems—some real, most imaginary or overblown—and promises to solve them, or to make those responsible pay. His “solutions” are high-octane nonsense, and he never follows through, but it seems to matter little.

A progressive populism could and should be much more high-minded, but there will be resemblances.

The Consumer Financial Protection Bureau became a carefully crafted policy after the concept won the day, but its popular appeal stemmed from the us versus them framing of the original idea. It’s regular people versus fat cats on Wall Street, and we need “a cop on the beat,” as Elizabeth Warren used to say, to make sure the fat cats, with all their money and clever lawyers, can’t fleece the public as a business model.

Health-care populism is similarly not going to succeed on the basis of policy detail and litmus tests. Bernie Sanders famously popularized the idea of Medicare for all without dotting any i’s or crossing any t’s. When other Democrats tried to beat him at his own game by publishing single-payer white papers, they basically flopped, in large part because making the stakes of reform tangible drained the populism out of the enterprise.

Learning from that experience still leaves a lot of populist room to maneuver. The available options become clearer and clearer once you reconceptualize populism as a representational exercise rather than a principled one. And that thought exercise is more productive than hoping vigilantes will make the difficult work of persuasive politics obsolete.