We’ve all been there… We needed a healthcare service or test. We got it. We thought it was covered. It wasn’t. Or maybe it was – but we had to fight for it, through a series of phone calls, letters and emails.

This extremely frustrating experience is too common. It’s left a sour taste in the mouths of many Americans and darkened our view of health insurance companies. Some people would rather do away with them all in favor of one insurer, the government, in what they call a “Medicare for all” (or single-payer) model. This is a leap we should not make. 

Two recent news stories have garnered some bad press for insurance companies Anthem and Aetna. But we ought to consider who’s really the bad guy in these scenarios. Is it the insurance company? Bad government policy? Or someone else?

First, Anthem.

Anthem denied a woman’s ER visit claim because she had ovarian cysts – not appendicitis. The former diagnosis is not an emergency; the latter would have been. But a new Anthem policy only covers visits to the ER that are, in fact, emergencies.

This policy has obvious problems. While it’s good to examine ways to combat the abuse of the ER (it should only be for emergencies, after all), it’s hard in many cases to ask patients to determine for themselves if they are in fact having an emergency.

ER use has increased – not decreased – under the ACA because many patients, even with “coverage” face difficulty accessing care via less costly avenues. Medicaid patients can have an especially hard time finding willing primary care doctors (the nationwide shortage is exacerbated by the programs low reimbursement rates).

Admittedly, the Medicaid population faces other challenges like inflexible work schedules and trouble accessing transportation, and so it’s harder to keep doctors appointments. That’s understandable. The ER provides the convenience of taking ALL patients regardless of insurance/ability to pay and *no appointment needed.*

Anthem’s mistake is making the “punishment” for being wrong about your ER visit too harsh. Perhaps people should pay something in this case, but not the full cost. That risks discouraging real emergency needs from heading to the ER.

After all, what is insurance for if not for ER visits? The ACA misguidedly forces insurers to cover too many *expected* costs (NOT what insurance is for) and unfortunately the result now is that insurers are experimenting with ways to avoid their most critical role — as a backstop against *unexpected* costs like ER visits. Anthem’s new ER policy deserves revisiting.

Second, Aetna.

Aetna is in hot water after a stunning admission from a (former) medical director. The Southern California physician in this role said he never looked at medical records before making determination about whether to pay for or deny claims.

In this case, this is NOT an Aetna policy – Aetna trains all medical directors to review all medical information, including records, but this rogue medical director failed to perform this critical piece of his job.  And Aetna failed in terms of oversight. Now the California insurance commissioner is looking into the situation.

As different as these two stories are, they should both give us pause: Do patients really want insurance companies acting as middlemen in our healthcare decisions? Do we trust them to make those decisions? Would we trust the government – in this role in a potential single-payer system – to perform this role any more fairly or effectively? Surely government-employed medical-claims-reviewers would make many of the same mistakes that we’ve seen in private industry. And keep in mind that it’s the government – via the misguided Affordable Care Act – that elevated the outsized role that insurance companies play in our health system in the first place.

Insurers may frustrate Americans, but that’s simply because they’re acting in an inappropriate capacity today as middlemen, rather than simply as providers of true insurance (contractual agreements to protect us from catastrophic costs).

No – the better solution to problems like those in the news lately is to empower the little guy (the patient), not the big guys (insurers or the government). A bottom-up health marketplace would give individual patients and consumers better information about what health services are available where and at what cost. And then we'd be free to make those decisions without fear that an unexpected bill lands in our mailbox much later.