Hanging

by a

Thread◊ by Caitlyn Allen, MPH DOI: 10.33940/interview/2021.3.9

Healthcare in the United States: Who’s really pulling the strings? Wendell Potter, former health insurance executive turned whistleblower, shares how the American people are being misled, signs a news story is just well-concealed propaganda, and how recognizing it as such is vital to making healthcare safer.

Caitlyn Allen: You came into the public eye in 2010 with the release The catalyst for wanting to leave the insurance industry was an of your book, Deadly Spin, which was a behind-the-scenes exposé incident that occurred in 2007 when you witnessed a makeshift on the influence that insurance companies have on healthcare in healthcare clinic at a fairgrounds in Virginia. What happened? the United States. Can you tell me more about that? In July 2007, I had gone back home to Tennessee to visit family, I Wendell Potter: Throughout my career, I remember just saying grew up there. And while I was there, I picked up my hometown to myself, I could write a book, but it never occurred to me that newspaper: the Kingsport Times-News. I read on the front page I would actually be able to do that. And it was not until after I about something that they were calling a “healthcare expedition” testified before Congress, and that was when I really came on the that was being held a few miles away. It was at a county fairground scene as a critic of the U.S. system of health insurance, that I had in a small community called Wise in Wise County, Virginia. The that opportunity. I testified before a Senate hearing in June 2009. article said that people were expected to drive from hundreds of And I had several invitations for temp television interviews after miles away to get care that they otherwise couldn’t afford. I never that, including the Bill Moyers Journal, which was seen by a few heard of this event or the organization that was putting it on, but agents in New York. this was the ninth year. And the article said people drove as far And I started getting calls from agents in New York, asking if I away as Ohio, South Carolina, and Georgia to this little hamlet in would be interested in writing a book. And that was what led to the coal mining section of southwest Virginia. Deadly Spin. I decided that this was an opportunity to go beyond I went there out of curiosity. At the time, I was writing a white that Senate testimony to pull the curtains back on how health paper for my company that would be used by the industry to try insurance companies in the United States really operate and also to get people to believe certain things about the uninsured in this how they spend enormous sums of money to influence public country. And the whole objective, as it turned out, was to try to get opinion and public policy and elections. people to think that being uninsured wasn’t such a big deal, and people in this country were largely uninsured by choice. I drove

◊Patient Safety Authority 84 I PatientSafetyJ.com I Vol. 3 No. 1 I March 2021 Disclosure: The author declares that they have no relevant or material financial interests. my dad’s car up to the fairground. And when I walked through precisely what I was doing in my job and being paid significantly If you don’t see or hear the source of the information, be skepti- the fairground gates, I was just stunned. It was almost like I had more than I was being paid as a journalist. And I had to own up to cal. If an organization is mentioned and you’ve never heard of it, Be Your Own Advocate: walked out of the U.S. into some refugee camp or MASH [Mobile the fact that I was a corporate propagandist and was misleading be skeptical. Even if you’ve heard of it, still be skeptical because Army Surgical Hospital] unit in some war-torn country because the American public to protect profits. a lot of these organizations, like the Partnership for America’s How to Tell if a News Story is Real­— people were there by the hundreds. They were queued up in lines Health Care Future, people may have heard about that, but they or Just Designed to Manipulate You that stretched out of sight. And I noticed that some of those lines Propaganda is so effective because people don’t know that haven’t taken the time to understand that’s a front group, that it led to barns and animal stalls. they’re being influenced. As you’ve been watching the news, is funded by industry money. Actually, by our money. Our money This was the county fairground, and people were really getting what are some of the more pernicious talking points regarding that we pay in premiums when we get healthcare. Part of our care in barns. Volunteers had cleaned up the animal stalls, put cur- healthcare coverage that you’ve heard? money goes to finance these campaigns. And, again, even if it’s someone that you recognize, step back and think, “What is the 1. Check to see if the tains over them to provide some means of privacy, but that’s what The talking points are the same as they always have been. 1,2 I witnessed. And it just shook me to my core. I couldn’t imagine motive here? What does this person have to gain from this?” It information has a source. Sometimes a few details will be changed, but typically, the talking takes some research. It’s not easy. But, certainly, the red flags are that this was happening in my country and just a few miles from points, the soundbites, are the same. You want people to fear Anyone can write “Studies where I grew up. I knew immediately that people in those lines terms like “socialized medicine,” “government-run healthcare,” change. And our communications campaigns, our propaganda “government takeover” of healthcare. Anything that, as you read show...” without citing who did could be people I grew up with. It could have been neighbors, campaigns, were designed to instill fear, uncertainty, and doubt in even relatives of mine. And I realized I could have been one of them, you can tell that your emotions are being manipulated, the research. the minds of Americans to get them to fear change; to be uncertain that’s really important. them had I not been fortunate, had I not been lucky to get a good that what’s being proposed in the way of reform would maybe not education and, ultimately, a good job. be in their best interest; and to doubt that those who are proposing One of the monumental shifts from the Affordable Care Act was it are on their side. Frankly, they’re fearmongering campaigns, I also knew that I had to take some responsibility for what I was enacting protections for people with preexisting conditions. and they’re very effective. They appeal to people’s emotions. And 2. If the source of the seeing because my job in the industry at Cigna was to perpetuate For those who may not remember, can you remind us what care the talking points, there aren’t terribly many of them, but you our current system, as dysfunctional as it is. And, of course, I was was like before that was enacted and how it’s since changed? information is listed, expected to obscure the dysfunctionality of our healthcare system want people to believe that what’s being proposed is “socialized and try to get people to think that health insurance companies are medicine,” that if this reform is passed and enacted that we’ll be It’s a good question because a lot of people either don’t know, research it! Look for: essential, that we have the best healthcare system in the world. I going down the slippery slope towards socialism. don’t remember, or have forgotten what it was like, but insurance • Funding: Can you tell how/ had all the evidence right in front of me that that was obviously not companies had the power to declare people uninsurable. A lot of And we—my peers and I across the industry—knew from research where the organization gets the case. I realized when I was looking at those people—who, by that we had done working with linguists and other communica- those folks in those long lines in Wise County, Virginia, were in the way, many of them were soaking wet because it had rained that tions experts and from polling, that people in this country just that boat. They had preexisting conditions, and insurance com- its money? panies had the power, which they exercised all the time, to reject morning and they weren’t about to lose their place in line, so they have a fear and a resistance to anything that they are told might be • History: How long has the group been around? were standing in the rain—I realized that what I was doing for a living socialism. It’s one that works, even though what’s being proposed someone’s application for coverage because of some illness in the was the exact opposite of what I tried to do when I was a journalist. is nowhere near socialism. You can get people to believe that just past, some condition that they had. And if they were willing to sell • URL: Unusual domain names typically indicate coverage to that person, they would be able to charge them a lot I made a commitment that day that I would have to figure out some by saying it and getting people who folks trust to say it, whether untruthful or intentionally misleading news.1 way other than that, other than what I was doing, to earn a living. they’re politicians or preachers or community leaders. It’s a very more money than someone who didn’t have that condition. And potent thing that’s used. Another is that what’s being proposed is it was a big contributing factor to the rising number of uninsured I was a newspaper reporter in my first career in Tennessee, in in this country. Nashville and Memphis, and then later in Washington, where I a “government takeover of healthcare,” or what’s being proposed was lucky to be able to cover the White House and the Congress is government-run healthcare, regardless of what the facts are. By the way, that was a fact that I was expected to obscure in that and Supreme Court for Scripps-Howard newspapers. I had a That’s what you want people to believe. And the industry has been white paper I mentioned. I was certainly not mentioning that a 3. Look for other sources to longer career in corporate public relations. But, as a reporter, I extraordinarily successful. big reason why so many Americans were uninsured was because verify a story and consider always tried to be honest, as objective as I could be, never to know- The industry works through front groups. The current one is they either couldn’t get or couldn’t afford coverage because of a ingly mislead people or to leave out pertinent details. But that’s called the Partnership for America’s Health Care Future. They’re preexisting condition. And that, frankly, applies to most of us in using fact-checking websites always operated out of a PR [public relations] firm, typically a PR this country or ultimately will. We had, by the time the Affordable like Snopes or PolitiFact.2 firm in Washington, that churns out these talking points and mis- Care Act was passed, almost 50 million people in this country leading statements and press releases and advertisements. It’s an who didn’t have health insurance. And a lot of them who did were extraordinarily effective campaign. But, again, you don’t have to paying far more than they should just because they’d been sick in have a lot of original thinking, you just have to repeat those talking the past or had a condition. 4. If you feel true anger after points, those soundbites, over and over and over again. And the The Affordable Care Act changed that. Insurance companies can reading a story, it may have The talking points are the industry has been doing it for decades, and it’s had its effect. no longer blackball people because of a preexisting condition. And there were hundreds [of conditions] that they used in the been written specifically to same as they always have I remember during the Affordable Care Act protests people past to either deny coverage or to charge people more. They can make you feel that way and “ holding up signs instructing the government to “keep [their] no longer do that. And they can’t charge people more for coverage been. Sometimes a few hands off my Medicare.” because of a preexisting condition. It was a horrible, horrible may have used misleading or situation. An untold number of people died because they couldn’t false information.1 Try to find details are different, but It’s true. I spoke at a town hall in New Jersey in September 2009. get the care they needed, because they couldn’t get insurance. It was during the debate on what became the Affordable Care other sources that discuss the topic. Act. It was a very contentious debate, and I saw people who were typically, the soundbites Playing devil’s advocate for a moment: What are the benefits to opposed to it with signs, “Get your government hands off my patients under our current system? For instance, does a private Medicare.” It was just unbelievable how people are so easily mis- are the same. You want system spurn more innovation or provide more choices than a led. We’re all more gullible than we think. people to fear change. more regulated system? Absolutely. Are there common red flags that we can look for to We do have some of the best doctors and some of the best hospitals Sources: help discern whether a news story is based in fact, or if it’s likely and medical facilities in the world, but they’re off limits to so many people, even with insurance, because of how insurance compa- 1. https://docs.google.com/document/d/10eA5-mCZLSS4MQY5Q well-disguised propaganda? Gb5ewC3VAL6pLkT53V_81ZyitM/edit nies create discrete networks of providers. That has been one of 2. https://libguides.ucmerced.edu/news/fact-check

86 I PatientSafetyJ.com I Vol. 3 No. 1 I March 2021 Patient Safety I Vol. 3 No. 1 I March 2021 I 87 What advice would you offer to a patient who is having difficulty of people didn’t even have that for their care this year. I’m sure with their insurance provider? For instance, if somebody has it’ll ramp back up. When they’re able to have these expeditions been denied a procedure or a treatment that their physicians again, I’m sure that the numbers will be even higher than they recommended, what should they do? have been. But, I would encourage executives to step out of their You should appeal the denial right off the bat. Work with your environment, to really talk to people, even their own employees. Everything I’ve mentioned here is uniquely American. physician and encourage or ask your physician to appeal that They might be astonished to understand that even employees of denial. Sometimes that could be done as a matter of routine, but insurance companies, those at the low end of the pay scale, often You don’t have these kinds“ of nightmare scenarios for you need to make sure that your doctor is appealing a denial. don’t have insurance. They can’t afford to take up the offer. Yes, a In many cases, the denials are overturned. And in many cases, lot of people who work for insurance companies are uninsured. so many people in other countries. They just don’t exist. insurance companies just automatically routinely deny requests They’re very low pay. It’s scandalous and outrageous. because they know that a lot of people just won’t bother to seek an appeal. Appeal that. It’s a legal right that people have. There’s a Back to the squeaky wheel idea, if the executives aren’t going process that can be lengthy, but it has to be expedited to a certain to come to the people, then maybe we can encourage more of extent because, in many cases, people need treatment right away. the people to come to the executives. Don’t waste time. Be your own advocate, but also try to find some- I think that’s a good idea. Interestingly, I had a Twitter thread a one else to help. Clearly, if you’re sick and you’re needing care, few months ago, and someone responded to one of my tweets with the “innovations” in our system. Even if people have insurance, Regarding these “innovations” you mentioned, one that seems your ability to be your own advocate is impaired, so it’s important the photograph and the address of the CEO of UnitedHealthcare, there are several barriers that insurance companies have erected most troubling is that you could go to the emergency room of a to try to find someone else, a family member or someone else, which is the largest health insurance company in the country. And to make it more difficult and more expensive for people to get the hospital that’s in-network, but you only find out later that your who can help advocate for you to help navigate the system and I got a call right away from the head of communications at United care that they really need. One “innovation” is the use of prior ER doctor was out-of-network. be a pain in the butt. Call the insurance companies. Call your asking if I could somehow remove that comment. I couldn’t, but authorization. In other words, doctors have to ask permission. They Yes. That’s a uniquely American dilemma. Everything I’ve men- doctor. Just make sure that you’re giving it a good old try and that got their attention. So, yes. And someone had also put some need authorization from an insurance company before proceeding tioned here is uniquely American. You don’t have this kind of even reach out to your state legislator, your member of Congress, placards in the lawn around the corporate headquarters as well, with a treatment, in many cases, even prescribing a medication. nightmare scenario for so many people in other countries. They your senator, the media. I know from years of experience in the too. That is something that is important for advocates to do for And these prior authorization requirements, frankly, have even just don’t exist. There’s no need for them. Americans grew up insurance industry that when that happens, your case gets ele- people to understand. You can get the attention of executives if gotten more aggressive since the Affordable Care Act was passed. with this system, so we can easily be misled into thinking that vated within the insurance company. It becomes what they refer you do things like that. That’s what they care about. Another “innovation” is high-deductible plans. We had them before it’s worse somewhere else, but we have the most expensive, the to as a “high-profile case.” And that gets special consideration. the Affordable Care Act was passed, but they weren’t as prevalent most unfair, inequitable healthcare system on the planet. When But my ultimate advice is to be a squeaky wheel. Don’t give up. With everything that we’ve just discussed, are you optimistic or as they are now. And now, a very high percentage of Americans are you talk about innovation ... obviously, there have been innova- Don’t assume that a denial is the final decision. pessimistic about the future of healthcare in the United States? in plans with such high deductibles that they’re foregoing the care tions—what I would refer to as the provider side—on treatments I’m optimistic. If I weren’t, I don’t think I would still be doing that they need because they don’t have enough money to meet their and development of new medications, new prescription drugs. Maybe if there are enough squeaky wheels, then maybe that’ll what I’m doing. Who knows? I could be tilting at windmills, but deductible, so they’re not picking up their prescriptions. They’re But, again, a lot of those innovations, which are valuable, are off be enough to drive some change. I know it’s possible to change the system. One of the organiza- not going to the doctor when they need to, which of course has limits to millions and millions of Americans because they can’t tions I lead is called the Center for Health and Democracy. And repercussions on their health, both short- and long-term. afford it, or the facility is not in-network or the insurance company We need a lot more squeaky wheels. We need people to advocate not only for themselves but for a better system. We need to be the word “democracy” is there intentionally. And here’s why: Another so-called “innovation” from the insurance industry are won’t approve a prescription for a medication your doctor says you We need to reduce the power and influence of my old industry need. So, yes, there’s innovation, but only, in many cases, for a few. really outraged at what’s going on. And that’s one of the things these narrow networks that I referenced. Every health plan has I’m trying to do is to get people to understand this system is so and other big entities, for their big corporations and their trade its own set of doctors and hospitals that you can use. And if you broken. We should be outraged. groups have enormous power to influence how we think, how our go out of network, you likely will get little if any coverage for And it’s not like we have the health outcomes to support hav- public officials are elected. They influence elections in ways that ing such an expensive, inequitable system. Americans perform seeing that provider or going to that facility. So, yes, we’ve had There’s a divide between health insurance executives and every- we don’t really understand, and they influence public policy. We some innovation, but in my view, on the insurance side of it, the worse in almost every outcome you can think of. So what are we need to attack that. Money and politics in this country is a big, getting for all this money that we’re paying? day folks. They’re not seeing the impact their decisions are hav- innovations have been detrimental. ing on real people. Would that help? And if so, realistically, how big problem. Now, you mentioned the word “choice,” and some people will You’re exactly right. The Commonwealth Fund assesses the per- could we change that? Anyhow, the point is I am optimistic. I think it’s going to be a formance of health systems. They’ve done this for a long time. I point to that and say, “Well, Americans have more choice of health I think it would help. The reason I changed my life and my career challenge because of the power and influence of the industry’s plans,” for example. That’s not the choice that Americans really think they look at about 11 countries. And almost every metric best interests. We need to curb that power in many different ways, that they look at, we’re at or near the bottom. was allowing myself to be in a position where I saw something I value. What they value most is a choice of doctors and hospitals. otherwise wouldn’t see. Most executives don’t do that. And they and we need to keep advocating for reform. And we are bewildered by the choices that we often have of health steer far away from an experience like that. I often talk about my There is a lot more support for sweeping reform than a lot of folks insurance companies. If you buy an insurance policy through the Do you think healthcare itself would be safer if more people former CEO who had such privilege, so many perks of the job. A might realize, so that gives me a lot of hope. exchanges in this country, it’s hard to figure out which one is the had access to it? driver would pick him up in the morning, bring him to the build- best deal for you. And almost all of them have high deductibles. I absolutely think healthcare would be safer. There’s a lot more ing. He would go to his office in a private elevator. If he needed to So, yes, there has been innovation. Another thing about choice, Wendell Potter is a former health insurance executive who had a “crisis that needs to be done beyond getting people the access to care go out of town, and I traveled with him quite a bit, the driver would by the way, is that the opponents of reform often use that word. of conscience,” becoming disgusted with America’s broken healthcare that they need. Comprehensive reform could certainly address take us to the airport. We would take a private plane to wherever system after years of helping the industry mislead Americans. Potter I wrote a New York Times op-ed about that earlier this year. They patient safety in ways that we have not. we were going. When you live a life like that, you can be so far walked away from his job at Cigna, one of the country’s largest health say that we want to have choice and that reform will take choice removed from the way most Americans live. And you don’t have an We don’t have a national system. Health insurance, and healthcare insurers, in 2008 and became a vocal critic of the insurance industry away from us. But when you stop and think about it, we—partic- understanding really of the consequences of the actions that you delivery, is largely regulated at the state level, so it varies from and a leading advocate of reform. ularly those of us who get coverage through our employers—don’t and your fellow executives make, the decisions that they make. state to state. But back to safety; one way of looking at it is that we have the choice of health insurance carrier. Our employer makes don’t really have an adequate safety net in this country. GoFundMe I don’t know how you can change that. I wish that they would go that decision. We might have two or three options from the same *The views and opinions expressed here are those of the participants and may not and these pop-up medical clinics are not a real safety net. And to Wise County, Virginia, to see, to this day, how people line up reflect the opinions or positions of the Patient Safety Authority or the Commonwealth insurance company, but more often than not, they all have high many people in many states are not eligible for Medicaid, because by the hundreds to get care in barns and animals stalls. That has of Pennsylvania. deductibles. And it is just a matter of guessing and gambling on some states have not expanded the Medicaid program. We have a not ended. The Affordable Care Act did not end that. The pan- how healthy we are going to be over the next year. This article is published under the Creative Commons Attribution- lot of work to do improving the so-called safety net in this country. demic put a pause on it. They couldn’t do that this year, so a lot NonCommercial license.

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