November 5, 2022
by Carla Hay
Directed by Sandra Alvarez
Culture Representation: Filmed in 2019 and 2020, in Pennsylvania and Atlanta, the documentary “InHospitable” features a predominantly white group of people (with some African Americans, Latinos and Asians), who are healthcare experts or hospital patients, discussing how profit-oriented business decisions from hospitals can be detrimental to the health care of patients.
Culture Clash: The documentary tells the personal stories of some patients in Pennsylvania who were affected by a business feud between healthcare companies University of Pittsburgh Medical Center (UPMC) and Highmark.
Culture Audience: “InHospitable” will primarily appeal to people who are interested in behind-the-scenes revelations of how hospitals actively play a role in the rising costs of healthcare in the United States.
“InHospitable” is an unsettling but necessary warning to anyone concerned about U.S. health care. This enlightening documentary shows what can happen when non-profit hospitals act like greedy corporations that care more about profits than patients. Although “InHospitable” focuses on a healthcare problem in the Pittsburgh/western Pennsylvania area, the documentary makes it clear that this is a problem that can happen to any region of the United States and can affect millions of people.
Directed by Sandra Alvarez, “InHospitable,” which was filmed in 2019 and 2020, puts a spotlight on a business feud between healthcare companies University of Pittsburgh Medical Center (UPMC) and Highmark. Both are non-profit groups that generate millions in profits every year. UPMC and Highmark own and operate hospitals and have their own insurance companies. UPMC is the largest employer in Pennsylvania.
In 2013, Highmark made a big move to compete with the virtual monopoly that UPMC had in the hospital business in Pennsylvania: Highmark made a $1 billion purchase of West Penn Allegheny Health System, thereby greatly increasing the number of hospitals that Highmark owned in Pennsylvania. In response, UPMC announced that it would no longer accept patients who had Highmark health insurance. This decision caused tremendous turmoil for Highmark-insured patients being treated at UPMC hospitals but couldn’t afford any other health insurance. And so, in 2014, Pennsylvania’s governor and state attorney intervened and negotiated a five-year contract, which was also called a “consent decree,” that had UPMC and Highmark essentially agree to not to deny health care to each other’s patients.
“InHospitable” mostly chronicles the months leading up to July 2019, when the contract was due to expire. Untold numbers of Highmark-insured patients treated at UPMC hospitals were starting to panic over losing their healthcare services at UPMC. Grassroots groups began to have town hall meetings and protests to bring attention to this healthcare crisis and demand that lawmakers and healthcare company officials do something about it.
The documentary focuses on three middle-aged people in particular who were affected by this healthcare crisis and participated in this activism. All of them had Highmark insurance but received healthcare from UPMC. The three activists who are featured prominently in “InHospitable” are:
- Vicki Arnett (a nurse who worked for UPMC), the caregiver of her husband Maurice Arnett, a patient with cancer of the liver and colon.
- Evie Bodick, a patient who says she had breast cancer and lung cancer twice and has a pacemaker.
- Beth McCracken, a patient with a rare form of cancer that has caused her face to have partial paralysis.
The health insurance situation got so bad for Vicki and Maurice Arnett, the closest cancer treatment center they could find that would take their Highmark insurance was in Atlanta. The documentary shows the couple going to Atlanta for an appointment at Cancer Treatment Centers of America. Vicki mentions that although the couple had to pay for the travel expenses out of their limited budget, the overall cost would have been higher if Maurice had to get the cancer treatment outside of the Highmark insurance network.
Bodick mentions that she has five different doctors at UPMC, and to change these doctors would be detrimental to her recovery. In a documentary interview, Bodick says at one point in her life, she was given just six months to live, but she defied those expectations, because she said the UPMC doctors helped save her life. Bodick wants to do whatever it takes to keep those doctors with the Highmark insurance that she has.
McCracken says that if she can’t use her Highmark insurance at UPMC, her insurance premium would be six times higher and her deductible would be 20 times higher than the amount that she has to pay through her Highmark insurance. McCracken says in a documentary interview: “My fight to maintain my health care has robbed me of the strength to care for my health … We should not have to choose between bankruptcy and health care.”
“InHospitable” explains through interviews with experts and statistical data why this problem exists. The documentary includes a brief history of how the U.S. hospital industry has evolved. There are three types of hospitals in the U.S.: non-profit hospitals (which are the majority, at 56.5%, according to 2019 stats from the American Hospital Association); for-profit hospitals (24.9%); and government-owned hospitals (18.6%). Non-profit hospitals have tax-exempt status on many things, under the condition that they give certain services to underprivileged people, like a charity is supposed to do.
Several healthcare economists who are interviewed in the documentary say that the problem is that non-profit hospitals get very little government regulation on how they spend their money. Non-profit hospitals are starting to act more like for-profit corporations, such as buying up the competition and forcing a near-monopoly of hospital health care in some areas. When a money-making group doesn’t have much competition, the tendency is to charge more money to the customers (in this case, the patients), who see the higher costs through an increase in insurance fees.
In other words, gone are the days when most hospitals were small charities. “This is a big, big business,” says Martin Graynor, a healthcare economist at Carnegie Mellon University. Graynor says that part of the reason why hospitals have become bigger and more expensive is because of technology, as hospitals compete to have the latest and most hi-tech equipment, which could affect their hospital ratings. Georgia State University’s Center for Law, Healthy and Safety director Erin Fuse Brown offers another explanation: “Hospital consolidation is the number-one driver of rising prices.”
The U.S. healthcare industry makes billions in profits. Darrell Gaskin, a healthcare economist at Johns Hopkins University, comments on how non-profits changed their business models: “What used to be a cost center now becomes a revenue and profit center.” But at what cost?
The documentary (which includes some eye-catching animation to illustrate the health industry issues) shows that although the United States spends more on health care per person than any other developed country in the world, a person’s life expectancy in the U.S. is the lowest (about 77 years old) for any developed country in the world. According to the Organisation for Economic Co-operation and Development (OECD) statistics from 2019, which are cited in the documentary, the U.S. spends about $10,586 per person per year on health care, compared to the second-highest spending country: Germany, which spends about $5,986 (in U.S. dollars) per person per year.
The implication is that people who benefit the most from health care in the U.S. are those who can afford the increasing costs. Everyone else might not get the health care that they need, which could explain the lower life expectancy. Either way, the cost-to-benefit ratio is still alarming if the results are lower life expectancies. “InHospitable” shows through real people’s stories how health insurance should be not be a business game played by greedy hospitals, because the very real consequences are that people will die if they can’t get the health care that they need if they can’t afford it.
Emily Gee, a healthcare economist for the Center of American Progress, says in the documentary: “Pittsburgh is a great example of what happens when most of the health insurance and resources get locked up into two competing firms. And I think these companies have less and less accountability.”
How did hospitals get so much unchecked power? Fuse Brown says, “Healthcare systems escape a lot of scrutiny because they are very politically powerful.” Federal Trade Commission commissioner Rebecca Kelly Slaughter comments, “Whenever we’re talking about political power and political influence, we cannot ignore the way our extremely broken campaign finance system affects decision making.” The documentary includes a statistic from a 2019 report from the Center for Responsive Politics that the U.S. healthcare industry spent $603 million in 2019 in U.S. political lobbying—more than any other industry.
What does that mean for the average person who’s experiencing a damaging problem such as having their health insurance no longer accepted by the place where they need to get medical treatment? “InHospitable” shows what several grassroots activists and their supporters did about the UPMC/Highmark problem in Pennsylvania in 2019. This footage is at the heart of the film.
In addition to having town hall meetings and peaceful protest rallies to persuade UPMC and Highmark to not let the two companies’ “consent decree” expire, activists enlisted the support of politician allies, such as Allegheny County controller Chelsa Wagner and Pennsylvania state representative Sara Innamorato, Summer Lee and Ed Gaines. “InHospitable” includes footage of these citizens meeting with lawmakers in the Pennsylvania state capital of Harrisburg. The documentary also shows other people who helped bring attention to this problem, including Pennsylvania Health Access Network patient advocate Erin Ninehouser and Pittsburgh Tribune-Review reporter Natasha Lindstrom.
“InHospitable” brings up the issue of racial and socioeconomic inequalities in U.S. healthcare, by mentioning how UPMC shut down its only hospital in Pittsburgh’s Braddock borough (which is populated by mostly African Americans, many of them low-income) in 2009. UMPC’s official reason for the shutdown was that the hospital wasn’t making enough money, which contradicts the main purpose of a non-profit. However, UPMC opened up a new hospital called UPMC East in a more affluent, mostly white neighborhood at a cost that was higher than it would have cost to keep UPMC’s Braddock hospital open.
Chuck Grassley, a U.S. Senator from Iowa, comments in the documentary: “The I.R.S. ought to be policing whether the non-profit organizations are really being non-profit, and are they carrying out the responsibilities under non-profit [laws].” Zack Cooper, a healthcare economist at Yale University, says that most healthcare economists believe many of these healthcare affordiability problems would be better solved if the U.S. government had better regulation of non-profit hospital finances.
In the meantime, “InHospitable” gives a very powerful chronicle of how everyday people in western Pennsylvania stood up for their rights against what seemed like big-business odds stacked against them. Vicki Arnett and Bodick are particularly passionate and outspoken when they speak to a crowd. If the documentary singles out any “villain,” it’s Jeffrey Ronoff, the CEO of UPMC. Bodick doesn’t mince words by saying that much of the UPMC problem with Highmark was caused “by his greed … This is a nightmare for people.” Ronoff declined to be interviewed for “InHospitable,” but the documentary includes some archival video clips of interviews that he did in 2009 and 2015.
An epilogue in “InHospitable” mentions that major non-profit healthcare groups—including UPMC, Highmark and the American Hospital Association (AHA) declined or did not respond to requests to participate in the documentary. AHA referred the “InHospitable” filmmakers to Charles River Associates, a consulting firm hired by the AHA to conduct a study on hospital consolidation. Charles River Associates executives Monica Noether and Sean May, who are interviewed in the documentary, say that consolidation exists to lower costs. But “InHospitable” questions if those lower costs are actually passed down to the patients.
The documentary also mentions that after hospital consolidations, the hospital’s non-management employees typically experience salaries decreases. (By contrast, upper-management employees at non-profit hospitals usually experience salary increases after hospital consolidations.) One of the highlights of the film is footage from a protest outside UPMC Montefiore over these lower wages and UPMC’s Highmark insurance ban. Another standout part of the documentary shows how protestors peacefully demanded to attend a UPMC Montefiore board meeting, even when officials decided at the last moment that only those who RSVP’ed would be able to attend.
Other people interviewed or featured in the documentary include medical doctor Elisabeth Rosenthal, author of “An American Sickness”; medical doctor Robert Pearl, former CEO of the Permanente Group; Ginny Bell, who is McCracken’s wife; Joe Bodick, who is Evie Bodick’s husband; Braddock resident/documentarian Tony Buba; Pat Busu, former White House advisor/co-founder of Doctor on Demand; cardiologist Dale Owen, CEO of Tyron Medical Partners; UPMC Presbyterian adminstrative assistant Nila Payton; medical doctor Farzad Mostashari, CEO and primary care expert at Aledade.
Sadly, one of the patients in “InHospitable” did not live to see this documentary released. Maurice Arnett passed away on May 8, 2020, at the age of 54. As much information that “InHospitable” packs in about the healthcare industry, the documentary never loses sight of the real people who are directly affected by healthcare industry problems.
“InHospitable” includes the outcome of the UPMC/Highmark conflict in 2019, and has additional footage from 2020 that addresses the COVID-19 pandemic. However, do not mistake “InHospitable” as a documentary that will become outdated, because it is a foreshadowing of what more people in America will experience if more hospitals make health insurance become a hindrance, not a help, to people who need health care.
Abramorama released “InHospitable” in select U.S. cinemas on September 30, 2022.