Dan Shea’s Aunt Kay was 83, vibrant and healthy in 2011, when she suffered terrible injuries in a head-on accident. Kay spent five months in the hospital rehabilitating and being repaired with so many metal parts that the family dubbed her “Iron Kay.”

Then the real fight began-one that changed Dan, a San Diego civic booster and Republican notable, into an implacable foe of insurance company tactics. He’s told Kay’s story in a short, even charming, video, “The Iron Lady,” that calmly exposes corporations trying to outwait Kay’s lifespan to preserve their profits.

Farmers and two affiliates of Nationwide have been resisting a settlement for more than two years and counting. It’s costing the corporations a bundle, but if Kay dies before their legal options run out, they’ll save a bundle. It’s a perfectly legal tactic, which Dan is determined to change. The fight is Kay’s reason for living through her pain.

Kay will never be the same: She can’t drive and can barely walk. She’s living with family and dependent on them. But she’s fully determined to get as far back to normal as possible.

Kay expected to at least recover financial independence, even after $800,000 in hospital bills. Both Kay and family of the 17-year-old boy in the truck were very well-insured by major companies. The boy was at fault, but there was no rancor between the families.

Then they encountered the insurance lawyers. It ultimately dawned on them that the insurance companies would benefit by delaying until Kay died, to make most of their liability disappear.

Kay originally did not want to sue, so Dan asked for mediation. Farmers Insurance, the boy’s insurer, agreed but stalled for months. Then the insurers offered a ridiculously low settlement–barely over half of the medical bills, much less her ongoing medical costs. Then they stalled some more and tried intimidating Kay with a long deposition about her life since adolescence.

When the case got to court in October of last year, within a few days a jury spurned the insurers’ argument that they really owed little, and awarded Kay $2.1 million dollars.

Kay hasn’t gotten a penny. The insurance companies stalled again, and on January 7 they demanded a new trial. When it’s denied, they can file for an appeal. That could string out for a year or two.

Dan Shea found that having plenty of insurance, no matter how much it costs in premiums, doesn’t mean the company will protect you when you need it. And that everything the insurers have done is within the law.

Dan and his family have the determination and resources to keep fighting, and Dan is calling on state legislators to fix these interminable delays.

The fix shouldn’t stop at auto and property insurance. There are also horrible insurance company incentives embedded in state medical malpractice law. For instance, if an infant is severely disabled by medical negligence, insurers for the doctor and hospital could have to pay millions for a lifetime of expert care.

If the baby somehow dies, its economic value dies, too. The law in California restricts dead-child lawsuits to such a low payout that grieving parents usually can’t even get a lawyer to take their case. So what incentive does an at-fault hospital or doctor have to keep that baby alive?

The same is true if the wronged patient suffers a terminal illness-why pay now if you can stall until the problem literally goes away?

We need more people with Dan’s determination to change this.

Posted by Judy Dugan, Research Director Emeritus for Consumer Watchdog.

An analysis just released by California’s health insurance exchange, Covered California, offers the first real insight into the depth of the Obamacare cancellation crisis.

About 450,000 of the 900,000 cancelled California policyholders will see rate hikes, according to the analysis released by Covered California.  That’s 50% of all cancelled Californians who will be paying more.

Most strikingly, half of those cancelled policyholders are getting policies that are little different from the ones cancelled, deemed by Covered California “comparable policies. ”   In other words, half of cancelled California policyholders are paying more, in some cases a lot more, for policies that are worth no more under the Affordable Care Act. Covered California reports the other half – 225,000 — will pay more for better benefits since they had “Thinner Plan.”

Despite the ugly stats, the Covered California’s board of political appointees voted to block President Obama’s call for extending cancellations for another year.  The Covered California contracts with health insurance companies, written at the insurers’ request, required them to cancel the 900,000 Californians. Thursday the board of political appointees refused to reverse course, arguing that would create more problems.

The happier headline Friday that 360,000 Californians have applied for coverage with California Covered is little surprise given that 900,000 policyholders have nowhere else to go because of its actions.   And that was the point of the cancellations – drive the individual policyholders into Covered California’s pool.

The problem is that pool has premiums that are much higher than what they should be and doctor and hospital networks that are much too small.  Cancelled policyholders would care less if they had comparable prices and comparable benefits.  And that’s what reformers should be fixing, rather than defending as reasonable.

35 states have rate regulation but not California. So benefits and premiums will continue to be out of whack until voters set the insurance industry and its political allies straight through a ballot measure next November, which requires approval by the elected insurance commissioner for rate hikes and benefit changes.

The Covered California analysis shows that 35% of cancelled policyholders will get subsidies for policies, so they will get rate relief under the Act. That doesn’t mean taxpayers aren’t paying too much for those policies, only that low income consumers are getting help.

The analysis, by one of the biggest boosters of the ACA, discredits an argument among other boosters that is troubling: why do we care that cancelled policyholders are losing ‘junk insurance.”

Our consumer group supported the ACA, and its research and education inspired its bans on junk insurance, preexisting condition limitations and medical underwriting.  The fact is, however, that cancelled policies in California are, by and large, not junk.   Their physician and hospital networks under old policies are far broader than under the Covered California plans. Of course, no one is watching, since our insurance commissioner has no power over prices.

Rate regulation is one answer, but until the 2014 election, when California voters can make that change, backers of the ACA also have to stop insisting its policies are always better, even if they cost more and cause doctor dislocation. That just won’t fly with a public that knows far better. Californians know when their doctors are not in the networks in the new plans and their premiums are higher.

If we want to save the ACA, then we better make it work. That includes acknowledging its flaws and trying to make them better.

In a state like California, without rate regulation and with much ACA support, it’s unthinkable that Covered California would buck the president and California Insurance Commissioner Dave Jones’ call for a reprieve on cancellations when its own numbers show 450,000 are paying more under the ACA.

It’s the continuation of a troubling logic that you are either for the ACA, and the relief it extends to 48 million uninsured, or against it. That type of reasoning will alienate the middle class, which is largely without subsidies and facing a real crisis in cost in states like California. These policyholders need relief too. And that means bucking the insurance industry, something its business partners at Covered California seem completely unwilling to do.

If the most ardent backers of the ACA don’t start to think like average citizens, there’s little reason to believe the vital center and muddled middle will continue to support the ACA.  It’s time to wake up and smell the rate hikes and insurance company shenanigans for what they are – wrong, plain and simple. Then we can work together on fixing them.

Posted by Jamie Court, author of The Progressive’s Guide to Raising Hell and President of Consumer Watchdog, a nonpartisan, nonprofit organization dedicated to providing an effective voice for taxpayers and consumers in an era when special interests dominate public discourse, government and politics. Visit us on Facebook and Twitter.

New Exchange has extraordinary levels of secrecy approved by the federal government

by Brian Leubitz

For the states that are proceeding with the setup of a state-based health insurance exchange, contracts are beginning to go out. Bids are coming from a number of sources, and the states are doing their best to get the best deals. And getting the best deal may require a temporary level of secrecy, but why would California’s need so much more secrecy than any other state? That’s what the federal government granted the state in a recent waiver:

The degree of secrecy afforded Covered California appears unique among states attempting to establish their own health insurance exchanges under President Barack Obama’s signature health law.

An Associated Press review of the 16 other states that have opted for state-run marketplaces shows the California agency was given powers that are the most restrictive in what information is required to be made public.(Michael Blood / AP)

A few other states have explicitly applied their open records’ act to the exchanges, while others have exempted commercial and financial information. But apparently we have gone the extra mile in authorizing the exchange and the exemption from our own open records laws:

In California, the explicit exclusions from open-records laws may run afoul of the state constitution, said Terry Francke, head of Californians Aware, a group that promotes government transparency.

If the Legislature wants to limit access, the state constitution requires it produce findings that demonstrate the need for shielding information from the public. In the bill that authorized the exchange, the Legislature devoted two sentences to address that issue. It argued the cloaked spending was “necessary” to protect “powers and obligations to negotiate on behalf of the public.”

There may be some issues, but in all likelihood this was totally permissible. In fact, closed bids will probably allow the state to produce better value for the system. It would be nice to see some of the data, even if it comes out a few years later. But for now, this AP story has Sacramento buzzing…

In response to consumer complaints and a class action lawsuit on behalf of HIV/AIDS patients in California, Anthem Blue Cross has agreed to suspend a program that would have barred patients from purchasing certain specialty medications at local pharmacies.  Under the program, patients would have been required to obtain their medications by mail order, threatening their health and privacy according to the lawsuit.

Blue Cross announced the suspension of the mail order program in a letter arriving in consumer’s mailboxes this week.  Download a copy of the letter here.

“The deferment of the mail order program is great news for thousands of Blue Cross customers with HIV/AIDS who were facing risks to their privacy and health,” said Jerry Flanagan, staff attorney for Consumer Watchdog.

The lawsuit, filed last month in San Diego Superior Court by Consumer Watchdog and Whatley Kallas LLC, alleges that the mandatory mail order program illegally targets HIV/AIDS patients. The lawsuit further alleges that due to the complex nature of HIV/AIDS drug regimens, patients rely on their local pharmacists who, working directly with the patients, monitor potentially life-threatening adverse drug interactions, and provide essential advice and counseling that helps HIV/AIDS patients and their families navigate the challenges of living with a chronic and often debilitating condition.  

In addition to the health concerns raised by the change in their continuity of care, HIV/AIDS patients have expressed serious concerns associated with a loss of privacy due to the proposed mail order program. For example, HIV/AIDS specialty medications often need to be delivered in refrigerated containers. Patients who live in apartment buildings or need to have their drugs delivered to their place of employment are concerned that neighbors and co-workers who are not aware of their condition will come to suspect that they are seriously ill.

Under the mail order program announced by Blue Cross in December and slated to go into effect on March 1, 2013, HIV/AIDS patients’ insurance policies would have no longer covered medications purchased at local pharmacies.

The deferment is intended to allow Blue Cross, Consumer Watchdog, and Whatley Kallas LCC time to develop a more consumer friendly program.

“Blue Cross should be commended for listening to the serious and heartfelt concerns of their customers who depend on local pharmacists for their life-saving medications,” said Edith Kallas of Whatley Kallas LLC. “We look forward to working with Blue Cross to ensure its mail order program benefits consumers without unfairly targeting its most vulnerable patients and providing them appropriate opportunities to choose what is best for them.”

Download the lawsuit filed by Consumer Watchdog and Whatley Kallas, LLC here.

In its quest for more profits, Anthem Blue Cross has begun telling patients who have very serious diseases and need so-called “specialty drugs” that they cannot use their local pharmacy where many have long term relationships, but must instead order their life-saving medications from a mail-order pharmacy.

As Los Angeles Times Consumer Columnist David Lazarus recently noted, specialty drugs are used for complex conditions and can cost thousands of dollars a month. Patients suffering from chronic diseases like HIV, cancer, and hemophilia use such medicines.

In the Los Angeles area HIV patients are particularly hard hit by Anthem’s unilateral decision that after Jan. 1, patients needing specialty drugs to treat their conditions must buy them from mail-order pharmacy CuraScript.

In a letter to patients, the insurance giant wrote:

“Using a retail pharmacy will be considered going out-of-network. And your plan doesn’t have coverage for that. So you’ll have to pay the full price of the drug.”

According to Lazarus Jacques Liberman, 57, of Cathedral City received one of the letters the other day. He is HIV-positive and takes a drug called Atripla to help prevent his condition from transforming into full-blown AIDS.

“Who is Anthem to tell me where I have to buy my medicine?” Lazarus quoted him as saying. “Why should I have to buy it from some mail-order company instead of the drugstore that I have been going to for a long time?”

But it’s more than just an in infringement on personal freedom. Patients who need specialty medicines suffer from complex disease that require complex treatment. The pharmacist is virtually a member of the treatment team offering advice and closely monitoring the patient’s condition.

David Balto, a Washington attorney who represents some of the specialty pharmacies, explains the relationship like this:

“Specialty pharmacies, the pharmacies that carry these rare, expensive drugs, build strong personal and clinical relationships with their patients, making sure that they receive the drugs they need when they need them. Most also provide a full slate of advising and counseling services to help patients and their families navigate the challenges of living with a chronic and often debilitating condition. Many specialty pharmacies also have programs to help low-income patients afford their ever rising co-pays.”

Anthem proposes to replace that relationship with an 800 number. Anything for a buck, I suppose.

What’s not clear yet is what can be done to stop this abuse. Consumer Watchdog is investigating.  If you’ve been affected by the change please let us know.

Reporters largely missed the point of a Commonwealth Fund study released this week, that looked at consumer savings under Obamacare’s 80-20 rule, the rule making insurance companies spend at least 80% of your premiums on health care, not overhead.

The authors started with a fact we already knew — that health insurance companies had to pay $1.1 billion in rebates for missing the MLR requirement in 2011 — and that big shiny number distracted the news media. But the authors zeroed in on a much more important fact. Insurance companies successfully reduced administrative costs by $1.184 billion in 2011, but they used those savings to increase profits instead of passing them on to consumers.

Clearly the 80-20 rule isn’t working to contain profits and hold down premiums, especially in states that don’t have tough regulation of insurance premiums.

California Insurance Commissioner Dave Jones launched an audit this week of the state’s largest health insurers to determine if consumers paid too much when insurers were actually saving money and boosting profits. The Commonwealth study found that in California, insurance companies increased profits for individual plans by $88 per member or about $90 million, even though administrative costs went down and every major insurance company imposed rate increases.

These results are more evidence that states need the ability to say no to rate manipulation. Otherwise, insurance companies will keep premiums artificially high to make sure profit numbers stay high too. As we warned HHS Secretary Sebelius more than two years ago:

“In the same way that a Hollywood agent who gets a 20 percent cut of an actor’s salary has an incentive to seek the highest salary, insurers will have incentive to increase health care costs and raise premiums so that their 15 percent or 20 percent cut is a larger dollar amount.”

As Jones said when announcing the audit:

“I have long pushed for the authority to reject excessive health insurance rate increases and this study provides further evidence of why this change in the law is long overdue in California. Health insurers and HMOs continue to impose double-digit premium increases each year and are making larger profits when selling to individuals and families even during these tough economic times.”

Californians will finally have the chance to stop them, by voting at the next ballot on an initiative measure to require health insurance companies to publicly justify rate increases and get approval before they take effect. Learn more at justifyrates.org

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Posted by Carmen Balber, Washington DC Director for Consumer Watchdog and Consumer Watchdog Campaign

It is a masterful spin by the self-described not-for-profit Blue Shield of California to announce that it is returning all but two percent of its profits to its customers, as though this were some act of humble generosity.  It’s a little like a supermarket announcing that from now on it’s going to give back (almost) all of your change.  (It’s actually worse than that, as I’ll explain.)

It is a masterful spin by the self-described not-for-profit Blue Shield of California to announce that it is returning all but two percent of its profits to its customers, as though this were some act of humble generosity.  It’s a little like a supermarket announcing that from now on it’s going to give back (almost) all of your change.  (It’s actually worse than that, as I’ll explain.)

All told, Blue Shield will have returned about $475 million in profits – $283 million that Blue Shield is crediting back in December plus about $167 million credited back earlier in the year for 2010 premiums as well as the $25 million the company distributed to doctors, hospitals and an as yet unnamed “community investment.”  But this should not be thought of as a sincere gift from a community-oriented nonprofit.  Rather, it’s nearly half a billion dollars that Blue Shield overcharged its policyholders and then held onto for months.  

Worse still, Blue Shield had to be pushed and prodded to do anything; this refund didn't just happen.  Blue Shield is only giving some money back because there was huge public pressure this year – from California Insurance Commissioner Dave Jones, from nurses and consumers who protested at their corporate offices, from lawmakers like Assemblyman Mike Feuer carrying legislation to regulate insurance companies and from news reporters investigating their rates and salaries.  

What’s more, the $283 million that will go to reducing policyholders’ December premium payments is utter chump change when given a full context:

Blue Shield, according to documents it files with the state of California, has more than $3 billion in excess surplus (“Tangible Net Equity excess” is the formal term).  That massive and ever growing pot of money is a profit account that Blue Shield uses to take policyholder premium out of the healthcare system so they can come back and charge those same policyholders high rates again next year.  Blue Shield could give back $280 million a month for an entire year and still have a enough money on hand to run a stable insurance company.  Or, to think of it a little differently, instead of giving families back a few hundred dollars for Christmas, they could just sell insurance at a reasonable premium and not stuff their own stockings with surplus.

To be sure, Blue Shield is angling for a feel good story it can tell politicians and voters when they next consider whether to enact a law or initiative regulating the premiums health insurance companies can charge.  That story may work with some politicians in Sacramento, but I doubt voters who are stuck overpaying for health insurance will be so easily spun.

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Doug Heller is the Executive Director of Consumer Watchdog. Visit our website at: www.ConsumerWatchdog.org.