The battle over healthcare continues, as heated a debate as it has ever been. And why not? Billions of dollars are at stake, in addition to the lives and well-being of its citizens. This being an election year, the rhetoric on the topic has been extensive. For the most part, the most common recommendation from the current crop of candidates is a re-tuning of our current system. Only a couple of voices are calling for a system more like that of the other developed countries, with some form of national health service, similar in many ways to the Medicare-for-All concept.

The US spends more per person on health care than any other country, by a significant margin. On average, other wealthy countries spend half as much per person on healthcare than the U.S. This despite having fewer office visits and shorter average hospital stays. But I would venture to say, as a country, by many measures, we are not getting our money’s worth. Tens of millions of Americans remain uninsured, while millions are in financial peril. One survey revealed almost 1 in 5 is currently being pursued by a collection agency over a medical debt.

Health care costs repeatedly top the list of consumer’s financial concerns. Many blame the high cost of medical care on the prices charged by hospitals, and to a lesser degree on doctors. But less scrutinized has been the role of the insurance companies. These middlemen between the patient and their provider have had a huge effect on the health care tab. Insurers are not guardians of our health care dollars. Too often, they agree to pay high prices then pass those high prices on to patients. Consequently, they have been raking in profits.

I think it’s safe to say the shareholders of the insurance companies are pretty happy with the way things are at this point. The business of health care is good. Some analysts have gone so far as to call this a golden age for the industry of medical insurance. The data reveals growth in both sales and profits for insurance companies. Thanks to government subsidies, insurers have benefitted from more than 20 million paying customers who are buying individual coverage under the Affordable Care Act and Medicaid expansion. Humana, which last week said it made more than $1 billion in profits in the second quarter, raised its earnings and revenue forecast for the rest of the year thanks to the growth in seniors signing up for Medicare Advantage plans.

Fewer seniors than ever have Medicare, but instead have been sold one of the ‘Medicare Advantage’ plans. Yet they are often unaware of this fact. These plans are another product the private insurers can sell. The government pays these privately-held companies to provide the appropriate population with health insurance. Naturally, the “privates” (private insurance companies) don’t do this as a gesture of magnanimity, they make money off of these sales. Being able to sell these Medicare Advantage plans has been a boon to profits. But most seniors are not informed they don’t have “real Medicare.” The differences can be important. The Advantage plans don’t have to follow Medicare’s rules and can make changes to their customer’s plans, which they do routinely.

The U.S. health insurance system has become excessively cryptic, complex, thriving on obfuscation. Most Americans have no idea how it all works on a very basic level. Deductibles and co-pays, premiums and secondaries…..what does it all mean? More importantly, how does it all work? Consumers are coming to understand they now have to cover services they never thought they would, and often never expected to need.

The insurance industry, in conjunction with governmental agencies, have conspired to make the practice of medicine an increasingly frustrating profession. Many physicians feel like an easily replaceable cog in the big machine which is modern day health care. Early on, dentistry took a very different path by eschewing any association with health insurance and relying strictly on fee for service. But the cost of our complex, technologically-demanding medical care makes self-pay unrealistic and impossible for most.

Many physicians have developed the vague suspicion it is the insurers that are practicing medicine. One particularly onerous method is the requirement for pre-certification. Sounds rather benign, doesn’t it? Unfortunately, it usually means committing a staff member to one phone call lasting sometimes 3 to 4 hours, trying to jump through the hoops set before you by the treacherous phone tree message systems. Suffice it to say, the “pre-cert” is an extremely successful way to delay or deny payments.

A decade ago, the opacity of prices was perhaps less pressing because medical expenses were more manageable. But now patients pay more and more for monthly premiums, and then, when they use these services, they pay higher copays, deductibles and coinsurance rates. Employers are equally captive to the rising prices. They have been funding health care for more than 150 million Americans and are seeing health care expenses eating up more and more of their budgets. Consequently, employers nationwide are passing on to their workers these rising health care costs by asking them to absorb a larger share of higher premiums.

A hundred years ago medical treatments were basic, cheap and not terribly effective. Insurance was developed not to make money, but to protect patient savings and keep hospitals afloat in the case of significant illness. Blue Cross, started in 1903, was then a not-for-profit institution. In 1993, before they went for-profit, insurers spent 95 cents out of every dollar of premiums on medical care (the “medical loss ratio”). To increase profits, the insurers simply spent less on care and more on activities like marketing, lobbying, administration and the paying out of dividends. The average medical loss ratio is now closer to 80 percent. In contrast, Medicare uses 98 percent of its funding for health care and only 2 percent for administration.

Health care in America is big business. To the patient, this is a very different discussion, much more than just dollars and nonsense. Dealing with insurance companies is a trying process, full of obfuscation. The problems with our health care system are many, but a list of the especially grievous must include the opacity of pricing, and the bizarre and often perverse financial incentives practiced by insurance companies. Perhaps most severe is an all-too common ethos of putting profits before patients.

Is a radical change in the system the prescription for success? With so much money and power invested in our current system, the effort required to fundamentally change this system is unlikely to be mustered. An expansion of health care and health insurance will be costly and may even cost more than it saves. But it could also turn out to provide great value, improving people’s access to care, fostering financial stability and overall well-being of the populace.

As is often the case, we are left with an over-riding question: is health care a right or a privilege? And should someone be profiting from another’s illness. Is it appropriate for some select few to make millions from the illness of others? No one is suggesting Medicare, a government agency, is efficient. But no one there is profiting from the medical care of their fellow citizen.

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments atdrcmclean@outlook.com.