I just got off the phone with my health insurance company. I had just received an Explanation of Benefits showing my deductible was not met, and a bill from a doctor showing that I owed the whole thing. Now this seemed curious. I have breast cancer and have already been through multiple imaging procedures, surgery, installation of a “portacath” and the first round of chemo. My deductible was met some time ago. The explanation? I have two deductibles on my plan, one for “in plan” providers and one for “out of plan.” I’d seen my dermatologist for something unrelated to the cancer, a doctor I’ve been seeing for over 15 years as insurance arrangements have come and gone in my life. Apparently she’s “out of plan.”
There are lots of, shall we say, nuances to health insurance coverage that you won’t know until you try to use it.
In my late twenties, that is, roughly 28-33 years ago, I maintained a private health insurance policy. I originally got it during a period when I didn’t have employer provided health insurance, and it seemed like a good idea to just keep it going; it was a really good deal. I don’t remember how much it cost when I first got it, but I remember it costing about $16/month just before the insurance mergers began and premiums started to skyrocket. It was through Blue Shield, which tended to pay 100% of doctor fees and 80% of hospital fees. Employer provided health insurance was generally through Blue Cross, which tended to pay 80% of doctor fees and 100% of hospital fees. And they didn’t coordinate benefits, so when I had some shoulder surgery in 1980, not only was it all paid for, but I also got some nice refunds. Really. A short time later the two companies merged, built an enormous new headquarters, and doubled their premiums.
Ah, surgery in the old days. In 1980 they “let” me come in the morning of my surgery instead of spending the preceding night in the hospital because my doctor trusted me not to eat too late. I met the anesthesiologist well before the time when he hooked me up, and he checked on me back in my room after I was fully awake. (My dad was an anesthesiologist. They used to “make rounds” of both pre- and post-surgical patients in the hospital.) They kept me in the hospital for at least two nights.
Fast forward to May, 2009. My insurance premium is $369/month, and no I don’t make anything like 23 times what I did then.
The day of surgery I arrived about noon for some additional imaging procedures before being admitted to the short stay unit. I think the actual operation was in the mid to late afternoon, removing a substantial chunk of breast and a bunch of lymph nodes and inserting a drain. I had a tough time coming out of the anesthetic in recovery and didn’t get back to a room until about 9 PM. Also had a rough night, including a nasty reaction to a pain med, but in the morning I was sent on my way with an ice pack and a quick lesson in caring for the drain.
And I don’t know how I am going to pay the rest of the bills. The first one marked “past due” arrived yesterday, and it’s for well over $2,000, and that’s just the start. And it’s not as if my other bills are going to be suspended just because I’m sick.
My point is it’s nearly impossible to get at the whole story on health care numbers. Not only am I paying 23 times as much for health insurance premiums as I did 29 years ago, I’m also paying (or trying to pay) an enormous amount more in co-pays, deductibles and other non-covered fees. And most years I pay for all of my medical care out of pocket because my deductibles are not met. And while there are more high tech tests and treatments, there is also an assembly line quality to health care that was not there 20 years ago.
The health insurance industry has managed to contort any concept of rational health care funding beyond recognition. We don’t really have an “insurance” system, in which you pay regular premiums but when you get sick you get taken care of. We don’t really have a “savings” system in which you pay into an account that you can use to pay your bills. It’s not that it’s a hybrid, but that it’s neither. We pay regular premiums, maybe for years on end that we don’t see a dime back, and we are still subject to bankrupting bills when we get sick.
Meanwhile, doctors and nurses work in assembly line environments in which they are expected to minimize their time with each patient. They enter their professions with far more debt and are far less well compensated than they were even a few years ago. Back in the day, most doctors were small businesspeople, who made their own decisions about how they balanced care and profit. Now many of them are employees who can be fired if they are not “efficient” enough.
Where is all the money going? More tests and expensive equipment? Sure, but that’s not enough. A lot of the money we pay for health care goes missing before it reaches care providers.
Somewhere along the line, health insurance exited the health system and became part of the financial system. It is now not so much a means of paying for health care as an excuse to disappear money into the black hole of the extraction economy. Just as Enron figured out that selling nothing for something was the ticket to incredible profits, just as the banking industry figured out that Ponzi was its patron saint, health insurers figured out that the route to incredible profits was to charge a captive market whatever they could get away with and then minimize payouts. As soon as their mission was narrowed to producing profits, all practices that furthered that were justified.
As far as insurance companies are concerned, when we talk about “fairness” we are speaking in irrelevancies. Their reason for being is to spread obligation and loss far and wide in order to concentrate wealth for a few. And they do it well. Because a captive market is the key to their success, they will fight like hell for the status quo. Meanwhile, across America, people with serious health challenges worry about whether their kids will pick up the phone when a bill collector calls. They triage their treatment along with their other bills. They face foreclosures, evictions and utility disconnections. Some of them stay sick because they can’t afford treatment. Some of them die for the same reason.
Insurance companies should be told to be happy they’re not being prosecuted under RICO. And then we should move on. The survival of the insurance industry should be the new irrelevancy.
I know that every time I pay my health insurance premium, a significant part of it goes to the bloated bureaucracy of the insurance company, including the people whose job it is to figure out how to deny benefits to sick people. Every time I pay a medical bill, I know that part of it is going to pay the doctor’s staff to comply with requirements designed by the insurance bureaucracy. And any investment losses the insurance companies sustain from playing in the “financial services” casino are taken out of our health care hide as well. It’s time for the insurance industry to take a tough cure. Too much of our health care dollars are going neither to treat disease nor to promote health.
Sometimes we can’t prevent or cure the diseases that take down our bodies, but it is human institutions that pile on the challenges for people who are sick. It’s human institutions that either facilitate access to health care or throw up barriers to it. And human institutions can be changed by humans.
As one of the lucky ones with health insurance, I may still lose everything due to this illness, if only because of timing. But I’d like to be among the last Americans to get the one-two punch of illness and financial ruin.