The Waste Management Division of the American Health Insurance Industry

On health literacy, community empowerment, and the remarkable ability of wealthy institutions to make their problems everyone else's responsibility.

Community-based healthcare navigation is the waste management division of the American health insurance industry.

There. I said it.

And before anyone from a community health organization throws a stapler at me, let me be clear: I am not criticizing the people doing the work. I'm asking why they're doing this particular work in the first place.

Because somewhere in America, a health insurance company has an entire legal department, compliance officers, policy analysts, actuaries, communications teams, and enough administrative infrastructure to launch a small country. And somewhere else in America, a volunteer at a community organization is explaining to a 78-year-old woman why her colonoscopy wasn't covered.

The insurance company calls this community partnership.

I call it waste management.

The Health Literacy Problem That Isn't Entirely a Health Literacy Problem

I recently came across a discussion about older adults and their understanding of health insurance benefits. The research identified disparities in benefits knowledge associated with income, education, race, and geography.

Fair enough. Those disparities matter.

But the discussion quickly turned toward educating older adults, improving health literacy, and empowering people to take a more active role in their healthcare.

And I found myself wondering why the proposed solution to an incomprehensible system was another workshop for the people trying to use it.

Actually, I wasn't wondering.

I was irritated.

We have normalized the idea that accessing healthcare requires additional training.

Think about that.

You purchase insurance. Or you qualify for insurance through a government program. You receive a card identifying you as someone entitled to certain benefits.

And then the real work begins.

You must understand deductibles, copayments, coinsurance, formularies, provider networks, prior authorizations, medical necessity determinations, exclusions, appeals, reimbursement procedures, and the subtle but financially consequential distinction between a service being covered and a service being covered under these particular circumstances.

You may also need to understand why the physician is in-network but the facility isn't. Or why the procedure is covered but the particular billing code isn't. Or why the insurance representative told you something different from what the written policy says.

And when people struggle to understand this arrangement, we identify a health literacy gap.

Whose literacy?

Because I would argue that the problem is not necessarily that people lack the knowledge required to navigate healthcare.

The problem may be that healthcare has been designed to require an unreasonable amount of specialized knowledge to access.

And those are two very different public health problems.

Margaret Doesn't Need Another Workshop

Let's imagine Margaret.

Margaret is 78 years old. She's raised a family, managed a household, paid bills, navigated decades of changing technology, and probably understands more about the practical administration of human life than most people designing healthcare engagement initiatives.

Margaret receives a notice explaining that a medical service she believed was covered has been denied.

The notice contains references to provisions, limitations, and procedures for requesting reconsideration.

Margaret calls the insurance company.

She waits.

She explains.

She is transferred.

She explains again.

Eventually, someone suggests that Margaret contact a community organization that provides assistance understanding insurance benefits.

Perhaps they even have a workshop.

Now imagine a corporate executive receiving the same denial.

Does he necessarily understand his benefits better than Margaret?

Not at all.

But he may have access to an assistant, a benefits administrator, a financial adviser, or someone else who can spend three hours on the telephone resolving the issue.

The difference isn't necessarily intelligence or education. It's the ability to outsource the administrative burden.

We're treating the ability to navigate health insurance as though it's a function of individual competence.

Meanwhile, people with the greatest financial resources can outsource the entire process.

Margaret gets a pamphlet.

And a workshop.

And perhaps a reassuring message about becoming more empowered in her healthcare journey.

Margaret would prefer that someone pay the claim.

We Want to Uplift Our Community Partners

This brings me to one of my favorite expressions in contemporary institutional language:

We want to uplift and empower our community partners to deliver their services.

Uplift them.

Empower them.

Partner with them.

Wonderful.

WITH WHAT?

Money?

Staff?

Infrastructure?

Long-term operating support?

Are we talking about a $3 million commitment to the community organization now expected to perform work the insurance company has made necessary?

Or are we talking about a photograph of two executives shaking hands, a press release celebrating the partnership, and a commemorative fruit bouquet?

Because I have questions.

Community organizations are extraordinarily valuable. They often possess something that large institutions spend enormous amounts of money attempting to manufacture: trust.

They know their communities. They understand local needs. They maintain relationships. They connect people to food, housing, transportation, recreation, social support, and opportunities for participation.

They do the work that makes communities function.

And increasingly, we're asking them to spend their limited resources helping people navigate the administrative machinery of institutions with vastly greater resources.

Consider the arrangement.

The insurance company develops and administers the benefits.

Its lawyers write the contractual language.

Its administrators establish the procedures.

Its systems determine eligibility, authorization, reimbursement, and denial.

And when people cannot understand or successfully navigate those procedures, we recruit community organizations to help.

The community didn't create the administrative waste. It inherited the landfill.

And now we're calling the cleanup operation empowerment.

The Opportunity Cost of Administrative Fog

There's a concept in economics called opportunity cost.

It describes the value of what we give up when we choose one use of our resources over another.

And I think we need to talk about the opportunity cost of community-based healthcare navigation.

Every hour a community worker spends deciphering an insurance denial is an hour unavailable for something else.

Every grant dollar devoted to helping residents understand administrative procedures is a dollar unavailable for another community need.

Every volunteer recruited to assist with insurance paperwork is a volunteer who might otherwise be organizing transportation, coordinating recreational opportunities, supporting families, or strengthening social connections.

These are not trivial activities.

They are part of the social infrastructure that influences health.

We recognize social connection, community participation, access to resources, and supportive environments as important determinants of health.

And then we divert the organizations positioned to strengthen those conditions into helping people navigate insurance bureaucracy.

We are consuming community capacity to compensate for institutional complexity.

And the extraordinary part is that we often describe this as progress.

Look how many people we helped navigate their benefits!

Look how many community partners we engaged!

Look how many educational sessions we delivered!

But what did those activities displace?

And why were they necessary?

A community organization should be able to devote its expertise to community needs rather than spend its limited capacity interpreting the administrative remains of policies written elsewhere.

The assistance may be essential today.

But that doesn't mean the need for assistance should be accepted as a permanent feature of the healthcare system.

Responsibility Is Shared Until Someone Has to Be Held Accountable

Here's where the language of partnership gets particularly interesting.

When institutions discuss improving healthcare access, everyone is a partner.

When they discuss improving outcomes, everyone shares responsibility.

When they celebrate success, everyone receives recognition.

But when a patient needs something the institution is contractually obligated to provide?

Suddenly, we're discussing eligibility criteria, documentation requirements, contractual exclusions, filing deadlines, and appeal procedures.

The responsibility is shared right up until someone has to be held accountable.

The community organization can help you understand the process.

But it cannot necessarily change the decision.

It can help you prepare an appeal.

But it cannot guarantee the appeal will succeed.

It can explain what the insurance company says its policy means.

But it cannot necessarily provide an authoritative interpretation of that policy.

And somewhere, an attorney is making sure the community organization includes a disclaimer explaining that its assistance does not constitute medical, legal, or financial advice.

Which raises an interesting question.

What, precisely, have we empowered the organization to do?

We've outsourced the assistance without outsourcing the authority.

The insurance company retains the power to determine coverage.

The community organization assumes some of the labor of helping people navigate that determination.

And the patient retains the consequences if the determination is unfavorable.

Responsibility without authority.

Assistance without accountability.

Partnership without shared decision-making power.

This isn't necessarily a failure of the community organization.

It is a structural limitation of the arrangement.

And it deserves considerably more scrutiny than another celebration of community engagement.

The Fruit Bouquet Is Probably Out of Network

Let's return briefly to our corporate executive.

Perhaps his assistant, Deborah, has spent the afternoon resolving his insurance problem.

Deborah has called three departments, obtained a reference number, requested a written determination, and submitted additional documentation.

She has also spent her lunch break attempting to resolve a billing issue involving her own family's healthcare.

Deborah is very good at navigating complicated systems.

She's had plenty of practice.

At the end of the quarter, the company recognizes her extraordinary contributions.

With a fruit bouquet.

Unfortunately, the bouquet exceeds the allowable appreciation budget.

Deborah is asked to complete an additional form.

I am exaggerating.

Slightly.

But the underlying absurdity is worth considering.

The people with the least authority over administrative complexity are often expected to devote the greatest amount of personal labor to overcoming it.

And sometimes we reward that labor with symbolic appreciation rather than changing the conditions that make it necessary.

Stop Measuring the Wound and Start Asking Why the Patient Is Bleeding

Public health is very good at measurement.

We measure disparities. We measure utilization. We measure knowledge. We measure engagement. We measure outcomes.

Measurement is essential.

But measurement is not, by itself, an intervention.

Imagine someone arriving at an emergency department with a gaping wound.

One clinician approaches with a tape measure to determine the dimensions of the wound.

Another begins calculating the rate of blood loss.

Both measurements may be useful.

But if nobody is attempting to stop the bleeding, we have a problem considerably larger than the quality of our data.

The same principle applies to healthcare access.

We can measure disparities in benefits knowledge by age, income, education, race, and geography.

We can identify populations experiencing greater difficulty navigating insurance.

We can develop interventions to improve their understanding.

But if we stop there, we risk documenting the consequences of institutional complexity while leaving its causes largely undisturbed.

And sometimes the measurement framework itself reinforces the problem.

If we define the outcome as improved patient knowledge, then a workshop that increases knowledge becomes a successful intervention.

But what if the more meaningful outcome is a reduction in the amount of specialized knowledge required to obtain care?

What if we measured how many steps a patient must complete to receive a covered service?

How many telephone calls?

How many transfers?

How many hours?

How many appeals?

How much unpaid labor?

And how much of that labor could be eliminated through changes in institutional procedures?

What if we measured the burden imposed by the system instead of primarily measuring the individual's ability to withstand it?

Now we're asking a different question.

Why Are We Treating the Water Instead of Investigating the Source?

Environmental health offers a useful framework for thinking about this problem.

When water is contaminated, we can measure the concentration of contaminants.

We can identify affected populations.

We can distribute filters, provide bottled water, and educate residents about reducing exposure.

Those interventions may be urgently necessary.

But they do not eliminate the need to investigate the source of contamination.

Where did it enter the system?

Who controlled that part of the infrastructure?

What safeguards were supposed to prevent it?

Who was responsible for monitoring those safeguards?

Why did they fail?

And who has the authority to correct the underlying problem?

The Flint water crisis illustrates why these questions matter.

The chemistry can establish the presence of dangerous lead contamination.

Epidemiology can investigate patterns of exposure and health consequences.

But neither a water sample nor a blood lead measurement, standing alone, explains the institutional decisions that allowed the crisis to develop and persist.

For that, we must examine governance, infrastructure, oversight, policy, and accountability.

The same distinction applies to healthcare administration.

Community navigators are often performing a form of downstream remediation.

They help people manage the consequences of administrative complexity after those consequences have reached the patient.

But what would upstream prevention look like?

Perhaps it would involve reducing unnecessary authorization requirements.

Simplifying benefits language.

Improving the accuracy and accessibility of coverage information.

Reducing contradictory communications.

Establishing clearer institutional responsibility for resolving problems.

And evaluating administrative systems according to the burden they impose on the people required to use them.

These changes would not eliminate every legitimate coverage dispute or the need for individualized assistance.

But they could reduce the volume of avoidable administrative work that patients and community organizations are currently expected to absorb.

Waste management deals with what has already been produced. Prevention asks why we're producing so much waste in the first place.

This Is Also a Disability Access Problem

For disabled people and their families, administrative navigation can be particularly consequential.

Accessing healthcare, therapies, assistive technology, accommodations, and support services may involve multiple agencies, funding sources, eligibility systems, and authorization procedures.

A family might need to coordinate among a physician, an insurer, a school, a government agency, and a community provider to obtain services that are individually recognized as necessary.

Each institution may have its own forms, deadlines, definitions, and documentation requirements.

And each may operate as though the family has unlimited time to coordinate the process.

When families struggle, the response is often additional information, additional training, or another referral to a resource navigator.

But difficulty navigating fragmented systems should not automatically be interpreted as a deficit in the person attempting to navigate them.

Sometimes the problem is the fragmentation.

Sometimes the barrier is the administrative process itself.

And sometimes the people being asked to demonstrate greater competence have already become extraordinarily competent at navigating systems that should never have required so much of them.

The ability to endure an inaccessible system should not be confused with evidence that the system is accessible.

Who Produces the Complexity, and Who Pays to Clean It Up?

I want community-based healthcare organizations to succeed.

I want them funded.

I want their expertise respected.

I want their relationships with the communities they serve recognized as valuable public health infrastructure.

And I want people who need help navigating healthcare to receive that help.

But I also want us to examine why so much help is necessary.

Because there is a difference between funding community organizations to address community needs and relying on them to absorb the administrative consequences of decisions made by institutions with far greater resources and authority.

If an insurance company wants to celebrate a community partnership, I would like to know what it has contributed.

Not simply how many people the partnership served.

How much funding did the organization receive?

Was that funding sufficient to cover the actual labor required?

Did the partnership give the organization any authority to resolve problems?

Did the insurer use what it learned to simplify its own procedures?

Did the administrative burden decrease?

Or did we simply build a more efficient system for helping people endure it?

These are questions of resource allocation, institutional accountability, and public health.

And they lead to a larger question:

When we invest in helping people navigate a barrier, are we also investing in removing the barrier?

Because if we aren't, we may be building an increasingly elaborate infrastructure around a problem we have decided not to solve.

We can call it navigation.

We can call it empowerment.

We can call it partnership.

But we should be honest about what we're asking communities to do.

They're cleaning up administrative waste they didn't produce, using resources they could have devoted to strengthening the communities they serve.

And somewhere, a very well-resourced institution is preparing a press release about how proud it is to support them.

The community did not create the waste. It inherited the landfill.

And I think it's time we started sending the cleanup bill upstream.