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Friday, July 17, 2009

Enough talk of "pre-existing conditions". How about the ones that insurance companies are supposed to pay for?
Posted by Jill | 5:05 AM
It seems to me that there is a giant honking hole in the talk in Congress and in the media talk about health care reform. We're hearing a lot about universal coverage, and "required to cover pre-existing conditions", and all that. What we aren't hearing is whether insurance companies are going to be required to cover what they're supposed to, or if they're going to be allowed to continue to drop people for making claims.

John Aravosis poses four questions people with insurance should ask themselves:
1. What's the annual limit on prescription benefits under your plan? Do you have a limit? I didn't think I did until last year when Blue Cross cut me off and I had to pay for my $250 a month asthma medicine, and more, out of my own pocket.

2. What's the lifetime limit on our major medical plan? What do I mean? Lots of health care plans only cover your major medical up until a certain point, then if you cost them too much, they cut you off. What's your cut off, and would getting cancer push you beyond that cut off?

3. How much does an appendectomy cost? We know from Joe that is costs $19,000 in Washington, DC. How much does your insurance cover? Joe has good insurance, and his still required him to pay $1,500 of that. What would yours require? You don't know? Then how do you know your insurance is so good?

4. Would your insurance pay for an MRI? For radiation and chemotherapy treatments? For a liver transplants? What if your mom or dad has cataracts? Or a detached retina? What about diabetes?

I'd like to add one to that list: Is your employer self-insured? Just because you get a card from Blue Cross, or Aetna, or UnitedHealth doesn't mean that they are providing the insurance. They may just be administering the plan while your employer pays the claims. If your employer is self-insured, and you, let's say, have a baby with cerebral palsy, or your spouse gets cancer, or you are overweight even if otherwise healthy, or you're over 50, does that put you on the "next to be laid off" list?

Most of us pay for car insurance. Companies make money off of car insurance because most of us will never file a claim. Same with homeowner's insurance, except that areas prone to natural disasters like Florida skew that picture a bit. But with health insurance, EVERYONE with a policy is going to file a claim sooner or later. And that makes the "insurance" model completely inappropriate for paying for health care services.

Conservatives like Newt Gingrich laud health savings accounts, which are designed to let you put money away tax-free for health costs. This is all well and good, but what about low-wage workers (and as the American wage base continues to collapse, that constitutes ever more Americans) who don't have any money left after paying for rent, food, and clothing for their kids to save money for health care? What happens if you are paralyzed in an accident, or have a stroke, or get cancer? Who can save the millions for health care that replacing insurance with HSAs would require?

As a system of "reform" that isn't going to make things better for anyone moves its way through Congress, fueled by insurance company money, we're hearing all kinds of talk about reducing costs by fostering "wellness." Yesterday Ron Reagan was on his radio show picking up the meme that now that she's the U.S. Surgeon General, it's time for Regina Benjamin to go on a diet to lose some weight "to set an example." You know what? We've had "examples." We've watched Oprah Winfrey, who can afford a personal trainer and a personal chef to prepare lovely salads for her every day instead of trying to find healthy options at the hot bar at the Fairway Market because you worked an 11 hour day and still have more work to do, gain and lose the same thirty pounds how many times now? We've watched Kirstie Alley gain and lose and gain and lose and gain evenmore every time. I can tell you this much: If Viagra worked as badly as diets do there would be Congressional hearings and John Ensign would be calling for it to be taken off the market.

Reform of the health care system is going to have to recognize that coverage of health care is not something that can be done on a for-profit model, because there is no risk analysis involved. Everyone gets sick. Sooner or later, everyone gets a catastrophic illness and dies, unless you're lucky to live to the age of ninety and the day after running a marathon and eating a lovely dinner, pass away peacefully in your sleep. No matter how much "wellness practices" you think you do, sooner or later you're going to have a baby, or a gall bladder attack, or sprain an ankle. Or you're going to work yourself into a stroke in an effort to keep your job so you don't have to go looking for work in an economy that's hemorrhaging jobs and those that remain don't pay enough to keep a roof over one's head.

But alas, that is not to be, because for now, insurance company campaign money and cheap talk of "socialism" trumps everything.

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Blogger SeDress said...
Just for clarification on the Health Savings accounts. They are usually tied to a high deductible insurance plan: with full coverage of claims once the deductible is met for the year. So if someone had an accident or terrible illness, they would 'only' have to come up with the deductible portion of the bill. Everything after that is covered. The problem (in my opinion) with the HSA's is that the premium isn't as much less than you would think it would be from a traditional plan. And the premiums and deductibles seem to rise each year as much as the standard plans do. The HSA plans are supposed to encourage people to be wiser about spending insurance dollars. What it actually seems to do in many cases is keep people from getting care they need, because they know they have to come up with the money up front for anything up to that high deductible. So it's much more likely that a little something will turn into a big something while the patient is deciding just how sick they really are. And then of course, if you do happen to reach that magic dollar amount, and max out your deductible, then it's awfully tempting to see the doctor for every little thing, to take care of any little health problem you have, because it's all paid for, for the rest of that plan year.