But none of these films that month. That title went to “John Q.,” a movie about health insurance.

Or, more precisely, a story about a desperate father — played by Denzel Washington — who takes a hospital emergency room hostage at gunpoint when his HMO refuses to cover a heart transplant for his young son.

John Q.’s violent quest for justice was, of course, fictional. And even in the film, no one ends up dead.

Tragically, that wasn’t the case on the streets of New York City on Dec. 4 when a gunman fatally shot Brian Thompson, CEO of health insurance giant UnitedHealthcare.

But there was nothing new about the anger at health insurers that Thompson’s shooting unleashed online — and which suspect Luigi Mangione expressed in a document .

In fact, eruptions of public rage have shadowed the American health care system for decades.

In the late 1990s and early 2000s, as “John Q.” was hitting movie screens, Americans were revolting against HMOs, whose practice of denying care to plan members to pad their bottom lines made them public enemy No. 1.

Just a few years later, health insurers stoked new ire for after people were diagnosed with expensive illnesses like cancer. More recently, insurers’ widening use of cumbersome prior authorization procedures that slow patients’ access to care has provoked yet another round of fury.

The cycle of outrage periodically turns on others in the health care industry as well. Exorbitant bills and aggressive collection tactics, such as garnishing patients’ wages, are sapping public trust in hospitals and other medical providers.

And drug companies — perennial poster children for greed and profiteering — have enraged Americans since at least the 1950s, when new “wonder drugs” like steroids were fueling a growing industry.

When Sen. Estes Kefauver, a Tennessee Democrat who had led an investigation of the Mafia, in 1959 to probe high prescription prices, his committee received mountains of mail from Americans who reported being fleeced by drugmakers. One retired rail worker told of having to spend more than a third of his retirement income on medicines for himself and his wife.

All this public outcry has occasionally sparked change. President Barack Obama and congressional Democrats leveraged anger at in California to get the Affordable Care Act over the finish line in 2010, a landmark achievement that expanded health coverage to millions of Americans.

But more often, cycles of rage have been so much sound and fury, producing only modest reforms. In some cases, public anger has yielded more headaches for patients.

The HMO backlash in the late 1990s and early 2000s, for example, prompted employers — from whom about half of Americans get their health coverage — to . Many employers saw these plans as a way to hold down costs if they couldn’t limit patients’ choice of medical providers through HMOs. These deductibles, which can reach thousands of dollars a year, are driving tens of millions of Americans into debt.

To many on the left who have long argued for a single-payer, government-run health system, the obstacle to more meaningful relief has been the political power of the same industries — health insurers, drug companies, hospitals — that fuel patient anger.

These industries have indeed proven adept at resisting change that threatened their bottom lines. They’ve also benefited from a paradox in how Americans think about their health care.

Patients may get angry. They may even lose faith in the system. This year, quality fell to the lowest point since Gallup began asking about it in 2001, with 44% of Americans rating quality as excellent or good, down from a high of 62%.

Yet more than 70% said their own health care is excellent or good.

There is much debate about what accounts for this paradox. Are Americans just grateful to have the health protections they do? Are they satisfied because most don’t have to use the health care system on a regular basis? Do they simply like their doctor, in the way that voters routinely say they like their own member of Congress but hate Washington politicians? Or do they worry that no matter how frustrating the current system can be, any change risks making the situation worse?

The answer is probably a bit of all of this. Together, such sentiments represent a major challenge for those who hope the current wave of anger at health insurers will drive big improvements.

Could that change? Maybe. These are volatile and unpredictable political times. And the pressure of big medical bills is real. Medical debt, in particular, is exacting a fearsome toll on millions of Americans, Ñî¹óåú´«Ã½Ò•îl Health News’ reporting has shown.

But to drive change, advocates looking to harness public anger at the health care industry probably need to rethink their favored solutions. Old ideas like “Medicare for All,” long cherished on the left, or a deregulated health care market, long championed by the right, haven’t swayed Americans so far, no matter how angry they’ve been.

I don’t know when we’ll see meaningful alternatives. One thing that’s almost certainly on the way: Hollywood’s spin on the death of a health insurance executive gunned down in Midtown Manhattan.

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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“We were doing so much work treating people with hypertension and diabetes, we thought those drugs would be on the list,” said Dr. Joel Hyatt, then Kaiser’s quality management director in Southern California.

Instead, hydrocodone, a generic opioid painkiller, led the list. OxyContin was near the top, even though the HMO didn’t subsidize it and patients had to pay for it themselves.

At the time, few if any physicians were talking about an “opioid epidemic.” But to the doctors in the room, the slides told a bleak story: Narcotics were being dispensed in numbers and doses higher than any of them had ever seen. The potential for addiction and overdoses among patients was frightening, something doctors around the country would later realize.

“People [were] getting prescriptions for a thousand pills,” said Steve Steinberg, a Kaiser family doctor who attended the meeting. “The numbers were so striking that it led us to look into it.”

Thus began an effort by Hyatt, Steinberg and a task force of others at Kaiser Permanente-Southern California to change how their colleagues practiced, and thought about, pain management. (Kaiser Health News is not affiliated with Kaiser Permanente.)

Taking advantage of the HMO’s massive health data system and its status as both insurer and health provider, the Southern California Kaiser doctors set about tapering the number of patients on high doses of narcotic painkillers. They reprogrammed computer software for doctors, developed new urine tests for patients and empowered pharmacists to question potentially excessive prescriptions.

They also pushed colleagues to expand the use of non-drug options for chronic pain sufferers: physical therapy, acupuncture, cognitive behavioral therapy, healthier diets and increased exercise.

Five years into its initiative, Kaiser’s Southern California operation reports prescriptions of opioids have plunged.

Prescriptions of opioid pills such as Vicodin and Percocet in amounts greater than 200 tablets dropped from 2,500 a month to almost zero, according to the HMO. So, too, have prescriptions that include potentially dangerous combinations of muscle relaxants, anti-anxiety medications and opioids, as well as prescriptions of brand-name opioids in general.

Kaiser patients coming out of routine surgery no longer receive 60 Vicodin, a month’s worth of pills for what are usually a few days of pain, Hyatt says. Now “you would probably be given no more than 18” pills of generic hydrocodone.

Kaiser is deploying these strategies across the organization, and the prescription of opioids has fallen by a third since March 2015, officials at Kaiser’s Oakland headquarters said.

Researchers at the federal Centers for Disease Control and Prevention in Atlanta say in an upcoming paper that Kaiser has struck a good balance between reducing prescriptions and managing patients’ pain.

“It’s important to demonstrate that, yes, it’s possible and that action can be taken now,” said behavioral scientist Jan Losby, the paper’s lead author.

But it’s not clear whether Southern California Kaiser’s approach can be adopted with success outside large HMOS. Many doctors operate in smaller clinics, under intense time pressure and without much opportunity to talk about alternative treatments. Not many have access to the kind of data Kaiser collects.

Some patients and their advocates worry about denying patients pain drugs they really need, a concern that has gained traction nationally.

“Not prescribing is as bad as over-prescribing,” said Paul Gileno, founder and president of the Connecticut-based U.S. Pain Foundation, an advocacy organization for chronic-pain patients. “We don’t want all or nothing. We want that balance.”

Kaiser patient Nancy Walter, who has experienced chronic pain since a serious motorcycle accident, agrees.

“They found something that worked and then they kicked me out,” said Walter, 59, of Brentwood, California. “It’s utterly ridiculous. I’m not going to sell this stuff. I need it. It’s hard enough to get it.”

A Hard Time Saying No

After that 2009 meeting, Steinberg began to study Kaiser’s centralized patient data system. The statistics showed that doctors regularly were boosting the dosage for hundreds of patients by about 30 percent every six months, Steinberg found.

Particularly disturbing was the high number of branded opioids that Kaiser doctors prescribed — Vicodin and Percocet, especially — instead of generic hydrocodone or oxycodone. Brand-name pills are more popular on the street and more likely to end up on the black market.

Soon Steinberg, Hyatt and other physicians were talking to colleagues at the health plan’s 14 medical centers in the region, citing studies that connected over-prescribing to overdoses.

“We [used] the same type of strategy that Pharma used,” said drug use manager Denis Matsuoka, referring to the big drug companies. To promote opioid prescribing years ago, Big Pharma offered free seminar lunches, handed out pens and other knickknacks to reinforce essential messages. Kaiser did the same — to reduce prescriptions rather than boost them.

Still, physicians had a hard time saying no while face-to-face with insistent patients. So Steinberg asked Kaiser’s tech people to reprogram the computer records system for doctors to guide their decisions in the clinic.

“We’re … providing the choices to the doctors, with the ones we want them to prefer at the top: Tylenol, Motrin, physical therapy, meditation, exercise,” Hyatt said. “Down at the very bottom are opioids.”

Today, a Kaiser physician about to prescribe OxyContin will receive an alert that the drug has a high risk of abuse. A doctor about to prescribe a benzodiazepine to a patient already receiving an opiate painkiller — a dangerous combination — gets a large yellow alert on the computer screen, along with scientific articles describing the hazards of prescribing the two classes of drugs. The physician has to override the alert to go ahead with the prescription.

Meanwhile, Kaiser developed broader urine tests for opioids allowing doctors to establish verifiable agreements with patients about how much opiate medication they would take.

The simplest change was also the most difficult. It came from a pain specialist, Dr. Quan Nguyen, and it involved leveling with patients.

Time For The Talk

“We weren’t taught to have a conversation with patients,” Nguyen explained. So over the years, as he worked with people on high doses of narcotics who needed to taper down, he developed what he calls The Difficult Pain Conversation — and he presented his approach to many other doctors.

A 60-year-old grandmother named Maria, who asked that her last name not be used to protect her privacy, underwent the conversation three years ago. The Riverside resident was on high doses of fentanyl and hydrocodone for chronic back pain. She felt dopey, took long naps, forgot where she was at times and gained weight due to poor exercise and eating habits.

Dr. Kim Thai, a pain specialist at Kaiser Permanente, asked her to do things to help herself as he tapered her dosage, she said. “He was on my side,” Maria said. “It felt less scary.”

As the dosages dropped, Thai had her enroll in physical therapy and acupuncture; she joined a wellness program. Maria began eating better and walking up to 7,000 steps a day.

Three years later, Maria reports she no longer takes hydrocodone and is down to 25 micrograms of fentanyl every three, and sometimes up to five, days. She’s lost 34 pounds. She still has pain, but less than before, and said she’s learned to manage it better.

“I’m back to smiling,” she said. “I enjoy our grandchildren very much. I can actually go to family functions and remember what happened.”

Walter, the patient who had the motorcycle accident, had a less satisfactory experience with her doctors in Northern California. At first, she said she felt well-served by Kaiser’s pain management program. She liked having access to different therapies and specialized doctors who found a regimen that would work for her.

When Walter returned to her primary care doctor, she said, he prescribed enough to make her pain tolerable for a while — but when her pain increased, he refused to prescribe more narcotics, saying, “You don’t need it.”

She said she heard the same thing from a neurologist who was not a pain specialist. Neither doctor consulted her former pain specialist, she said. She felt she was treated like a junkie, she said, and now makes do with her original prescriptions that include methadone and muscle relaxants.

Dr. Ramana Naidu, an assistant professor of anesthesiology and pain specialist at University of California, San Francisco, agrees with the Kaiser approach overall but cautioned that weaning patients off of opioids should be done in a “slow and gradual manner” to avoid the risk of rebound pain and a withdrawal syndrome.

He said that while it’s important to discern whether patients are seeking prescriptions to abuse or sell opioids, pill counting and urine drug screens may introduce distrust into the patient-doctor relationship.

Kaiser’s Hyatt said the Kaiser approach is founded on building that trust. The biggest problem he sees is patients’ headlong rush for relief.

“Patients in America are impatient. They want a quick fix,” said Hyatt. “But I think we’ve made real progress. The more we can arm physicians and pharmacists with the right information and scripting, the more likely the right thing is going to happen.”

This story was produced by , which publishes , a service of the .

California Healthline senior editor Barbara Feder Ostrov contributed to this story.

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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The plans, usually known as preferred provider organizations or PPOs, pay for a portion of the costs of out-of-network hospitals and physicians. They are the most common type offered by employers, and some consumers in the individual marketplaces find them more appealing than health maintenance organizations and other policies that pay only for medical facilities and doctors with whom they have contracts.

The price gap between PPOs and HMOs is growing in many places where both are offered. In Chicago, the least expensive silver PPO next year will cost $270 a month, $75 more than the least expensive silver HMO, and 27 percent more than the cheapest silver plan costs now. Meanwhile, the price of the least expensive silver HMO in Chicago is dropping by 12 percent.

In Salt Lake City, the premium for the only silver PPO is growing by 30 percent, nearly four times the increase for the least expensive HMO. In Philadelphia, the cheapest silver PPO will be $389, $113 more than the cheapest HMO. This year, Philadelphians wanting a silver open access plan had to pay just $66 more. As in many places, insurers also are selling different bronze, gold and platinum PPOs (the metals indicate how the insurer and patient divide the cost of care), but the cheapest plan in each tier in Philadelphia is an HMO.

In Houston, the only plans available through the federal exchange have closed networks. Blue Cross Blue Shield of Texas, which offered a PPO plan in Houston for 2015, cited rising costs as a reason it will not offer any open access plans next year. There is at least one PPO that consumers can purchase directly or through a broker, offered by the Memorial Hermann Health System, but it is not listed in the federal marketplace offerings so premium subsidies are not available.

“Everyone is up in arms,” said Jo Middleton, a Houston insurance broker. “I do not have a single client who is happy. They want PPOs and can’t get them. They want the flexibility.”

The biggest complaint, she said, is not that the HMOs don’t allow out-of-network coverage, but that their networks are too small.

“If you are someone who needs several doctors and several specialists, it’s difficult to find a network they are all in,” Middleton said. “In many cases, the doctors may be in a network, but only have admitting privileges at a non-network hospital. In the 11 years I’ve been in the business, this is unprecedented.”

None of the plans available through the federal exchange in Houston include the city’s well-known MD Anderson Cancer Center in their networks. “It’s a huge problem,” said insurance broker J. Casey Lowery. “If you’re a cancer patient, think about it. All of a sudden you have to switch doctors.  Or, if you want to stay with a doctor because he saved your life, and now you’re in an HMO, you have no coverage.”

Dan Fontaine, an administrator at MD Anderson, said some insurers did not invite the cancer center into their network. Others offered payment rates that he said “we don’t consider serious” because they were too low “and oftentimes less than what Medicare or Medicaid pay us.” He said the center was trying to make arrangements with insurers for patients who are in treatment now.

Plans with out-of-network benefits are not disappearing everywhere. Alaska, Arkansas and Wyoming are bucking the trend by only offering PPOs. Out-of-network costs even with PPOs can be prohibitively expensive since many PPOs will only cover a minority of costs, diminishing the difference from HMOs. Also, people who qualify for government premium subsidies can be insulated from the full cost of a PPO.

Allen Gjersvig, an executive at the Arizona Alliance for Community Health Centers, says one PPO in the state requires approval before seeing a specialist—a restriction often associated with HMOs—while there are HMOs that don’t mandate pre-approval of specialist visits. “The meaningfulness of HMO and PPO is starting to really blur,” he said.

Brokers say they are scrambling to help customers find new plans.

“I’m 31 and hardly go to the doctor,” said broker Michael Ledgerwood, president of the Houston Association of Health Underwriters. “If my doctor isn’t in the network, I don’t care. But my response would be quite different if I had more health care issues or saw more specialists.”

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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