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"Get a job!"
I have one.

"If you have a job, you can get insurance! If not, get a DIFFERENT job!"
Many people can't. I am fortunate enough that I can, and my employer even helps pay for part of the outrageous insurance rates.

"If you have insurance, you have health care!"
Well... maybe.

Sometimes, insurance doesn't cut it, particularly with the cost-cutting measures employers have to put in place these days to keep the business going.

My employer put in place an interesting insurance system "hack" to help mitigate the insane costs of health care in this country. Our main health care plan has a $10,000 deductible. That's pretty awful; $10,000 is instant bankruptcy for someone on my pay. However, we use a supplemental insurance scheme that reimburses the employee all but $500 of that deductible. So the process goes like this:

I get hospitalized for a week with an unusual condition. I get IV medicine, surgery, pills, and leave feeling a lot better than I did going in.

Naturally, that $10k deductible is hit almost instantaneously with the ER bill alone. The whole thing, however, is billed to the insurance company. They pay what they're going to pay and the hospital bills me for $13,500, split into approximately 700 individual bills. The secondary insurance kicks in and issues me a check for $9500, to cover the deductible minus $500. I put that in the bank, then write a check to the hospital for $10,000. So far, so good.

But my employer didn't tell me about the $3500 "out of pocket" expenses. Turns out, they didn't even KNOW about that part. See, the insurance company (the one with the $10k deductible) also simply refuses to pay $3500 of my medical bills. It's right in the insurance booklet. The $3500 is composed of numerous so-called "co-insurance" fees. "Co-insurance" is a legal term which means, roughly, "we're going to bill you for a percentage of this procedure even though we agree it was needed and agreed to cover it."

The "out-of-pocket" expense exists beyond the deductible and is buried deep on the insurance company's web site. So, it turns out, I inexplicably owe $3500, which is more than twice the amount of my own money I've ever had in my bank account at once in my 12 years as an American worker.

I apply for financial aid with the hospital, and, wonder of wonders, QUALIFY. I have three years to pay that $3500 now, interest and penalty free. Awesome. I can do that.

Now skip ahead 6 month to the present day.

My wife and I are expecting. We don't have a lot of money, but we've budgeted carefully and we can afford a baby. We're both in our 30s and don't want to put it off any longer. Of course, there will be another $4000 for the birth and such out of our pocket because of "co-insurance" and the deductible, but we are saving and will have some help from family. We'll manage.

A preliminary test shows high levels of a hormone that may indicate spina bifida, a rare but sometimes dangerous defect of the fetal spine. Our local health care provider can't provide the level II ultrasound needed to confirm or excluse diagnosis, so we are sent to an affiliated hospital 50 miles away in another state.

Problem: the hospital takes a look at our insurance, sees the high deductible, and requires payment of nearly $1000 up front for this test. Apparently, high deductible insurance is a "risk flag" and because we are out of state, this hospital won't even try to bill the insurance company for it.

$1000 is not far from what I make a month, net. That's before expenses like food, utilities, and rent. We're pretty wiped out already from the last round of medical bills, so... we canceled the test appointment. There really was no other option. No other nearby hospital will do the procedure without changing our provider, which is both undesirable on a personal level AND unaffordable by way of being outside the insurance network.

So there you have it. I am employed. I have insurance, and it's better insurance than many people have (albeit a bit unorthodox). All these advantages, and I still cannot afford to find out if our baby is healthy.

I'm not asking for money. I'm not looking for handouts. I'm not even looking for sympathy. I just to say to those right-wingers who chant "get a job!" like a mantra... Having a job is not enough. Having insurance is not enough. The health care system in this country is broken, and the coming insurance reforms are not going to fix it.

9:05 PM PT: Community spotlight? Republished? Reclist? I'm overwhelmed and very grateful! I hammered this out at the end of a workday to get it out of my head; I'm glad the message is one that resonates. Thank you all for the recs and messages of support!

Originally posted to a random idiot on Mon Nov 28, 2011 at 02:32 PM PST.

Also republished by Single Payer California and Community Spotlight.

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