American health care and ancient family values

© 2024 Gwen Dewar, Ph.D., all rights reserved

Who should decide whether a child gets access to life-saving care? Or if the child’s family should receive a crippling financial blow – one that might permanently and negatively alter the course of their lives? In traditional cultures throughout the world, folks share similar values about this: Some things should not be determined by the whims of profiteers.

You’ve rushed your child to the local hospital. The doctors determine that your child has a severe, or even life-threatening condition. It is medically necessary to transport your child – by air – to a facility for immediate surgery.

What do you do? It’s no-brainer. Your child’s life hangs in the balance. An air ambulance is necessary. So your child is transported, gets treated, and – we fervently hope – survives and thrives.

And then you get a surprise bill…for nearly $60,000, or maybe even more. Because your health insurance company decided to reject your doctors’ expert determination that the air ambulance was medically necessary.

On December 9^th, 2024, I heard about a case like this in a local news report. There was a happy ending, but only after local, investigative reporters got involved with the story.

Unfortunately, there have been many other cases like this in the United States. To see what I mean, do an online search, using the keywords “air ambulance bill parents.” Or read this account by Maura Kelly in a 2020 article for the peer-reviewed journal, Annals of Emergency Medicine.

Why do these things happen?

Americans already know why. Alone among affluent, industrialized nations, the United States allows the financial authorization of life-saving treatments to be decided by private corporations.

We’re also the only the only such nation that offers only a weird patchwork of health care insurance solutions, so that every life change (of employment, income, family size, or state of residence) can cause families to lose their health coverage, and force them to reapply to new plans.

It could be even worse. Before the passage of the Affordable Care Act, millions of Americans who didn’t get health insurance through an employer were either denied coverage because of pre-existing conditions, or offered coverage at such a high price it was totally unaffordable. And thanks to Medicaid, and to the national Children’s Health Insurance Program (CHIP), more than one third of American children receive health care coverage that would otherwise be unaffordable for their families.

But this highlights the vulnerable nature of the patchwork.

Working families at risk

Since 2023, nearly 4 million children were disenrolled from Medicaid and/or CHIP — approximately 70% for procedural reasons, such as parents not realizing what paperwork they had to submit to maintain coverage (Alker et al 2024). And Republican politicians have signaled their intentions to restrict Medicaid funding, stop the enhanced subsidies for the health plans offered through the Affordable Act marketplace, and weaken protections for folks with pre-existing conditions –including pregnancy (Orris and Heyison 2024).

Such actions would likely make millions of working families fall through the cracks — earning too much money to qualify for Medicaid, and too little to afford private insurance.

So health insurance is a huge part of what’s wrong with the U.S. health system. But it isn’t only that we have insurance companies trying to deny benefits in order to please their investors, or that many people can’t afford the health care coverage they need.

There’s also the question of allowing vital, public survival services (like air ambulances) to be controlled by someone other than medical caregivers and the people.

For example, consider these points about air ambulances.

1. People don’t get a choice about using air ambulances.

Something terrible happens. Decisions are made under dire circumstances. Patients rely on the expert advice of doctors – the folks best qualified to judge. Yet, in the cases we’ve discussed, health insurance companies have rejected those expert medical decisions.

2. People don’t get to choose which air ambulance services to use, which puts them at risk for dramatically higher bills.

What if the air ambulance isn’t “in network” with your insurance company? According to estimates, approximately 50% of air ambulance services have ended up being out of network (Turrini et al 2021). In 2021, U.S. lawmakers passed the “No Surprises Act,” which was designed to protect consumers in these situations. However, the Act has been challenged in the courts. So it remains to be seen how this will turn out. 

3. Air ambulances used to be run by hospitals. But nowadays, most air ambulance helicopters in the United States are under the control of just three private companies…and there have been huge markups on air ambulance services.

Put these factors together, and we can see this isn’t just a problem with the way Americans handle health insurance. It’s a problem with the way Americans handle many aspects of essential care.

Decades ago, most air ambulances were owned and operated by hospitals. Today, 73% of all air ambulance helicopters are owned by just three for-profit companies. And there is a crazy-big markup for this service.

In 2017, the median cost of an air ambulance in the United States was $36,000. Yet the operating costs represented only $6000 to $13,000 of this total.

Where am I getting these statistics? From Dan Goldbeck and Malcolm Mahoney, writing for the American Action Forum (AAF), a think tank that describes itself as “center-right on domestic economic and fiscal policy issues.” As these authors note, the “shockingly high price tag” of air ambulance services reflect the fact that “firms have the ability to inflate prices to exorbitantly high rates, often much higher than the operating cost.”

We can do better. It is part of our heritage to do much better.

As I have written elsewhere, the evolution of our species has depended on cooperation, sharing, and supporting families with children. Even today, the world’s remaining hunter-gatherers understand that raising children is a community effort — not a personal hobby. Everyone’s well-being — everyone’s survival — depends on each new generation growing up healthy, strong, smart. It simply isn’t possible for parents alone to make this happen. It’s too big a job. It has always been too big a job.

This understanding about our humanity has been shared by people in traditional cultures throughout the world. And I’m convinced that most Americans – regardless of their politics – agree with the basic premise: There are things in life – like essential medical care  – that should not be under the control of corporate profiteers.

But Americans have been stuck with a such a system, and it costs us. In a study comparing the United States with 10 other, high-income countries, researchers found that Americans were spending the most on health care — far more than anyone else. Yet they were also having the most trouble accessing affordable care.

Moreover, the United States ranked dead-last for health outcomes, including infant mortality and life expectancy after age 60. And it had “exceptionally poor performance” for two measures: Maternal mortality and avoidable mortality (Schneider et al 2021).

What would our ancient ancestors make of this? A society that has life-saving medicine and technology…and yet fails to use this power to support its members?

References

Goldbeck D and Mahoney M. 2023. Addressing the High Costs of Air Ambulance Services. American Action Forum. Accessed online December 15, 2024.

Kelly M. 2020. Sky-High Air Ambulance Prices. Ann Emerg Med76(5):A17-A20. doi: 10.1016/j.annemergmed.2020.09.447.

Orris A and Heyison C. 2024. Republican Health Coverage Proposals Would Increase Number of Uninsured, Raise People’s Costs. Center on Budget and Policy Priorities. Accessed online December 15 2024.

Schneider EC, et al. 2021. Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries (Commonwealth Fund, Aug. 2021). https://doi.org/10.26099/01dv-h208

Turrini G, Ruhter J, Chappel AR, and  DeLew N. 2021. Air Ambulance Use and Surprise Billing. (Issue Brief No. HP-2021-20). Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. September 2021.

Image credit: silhouette of toddler raising hand by PLFILM / Shutterstock

Image credit: helicopter by Davide Zanin Photography / shutterstock