no allergy meds for you…
This post is going to be a little unusual for this blog. Typically, I don’t spend a lot of time on healthcare other than trying to debunk pseudoscientific claims of homeopaths and vehement anti-vaccination activists from a scientific standpoint. But for the last month or so, I haven’t been able to turn on the TV or look at a news site without hearing about some new uproar over a potentially major overhaul of the American healthcare system based on unfounded panic, astroturfing or stubbornly ideological grounds.
It really doesn’t seem to matter that no one has seen the full and complete bill which may be voted on in Congress. In fact, those who oppose it are using this opportunity to grossly misinform the public and insist that should any change to the system pass, random bureaucrats will butt in between you and your doctor to decide the level of care you’ll receive based on their schedule of costs, even though there’s no blueprint for how the plan will actually work other than wild speculation and rumors coming from random pundits.
Now here’s the really funny part about this threat. This is exactly what we have now. It’s just that instead of a government official, we have a clerk from an insurance company decide whether we can get what our doctors prescribe us and our quality of care depends on who we work for or how much we’re willing to pay. Let me give you a routine, real life example of how insurance companies interfere to prevent your treatment from exceeding how much they’re willing to spend on covering you. Or in this case, me.
Friday of last week I went to my doctor because I’ve been having a little trouble with my allergies. He examined me and wrote a prescription for a well known medication with a slight stimulant. In theory, I should be able to go to the pharmacy, have them fill the script and allow my doctor’s treatment plan do its thing, right? Actually, no. When I went to pick up my prescribed pills, the pharmacy says that the insurance company won’t cover the prescription. Instead, they want me to receive another version of this medicine and buy the mild stimulant it contains over the counter. I’m of course free to pay $185 for each month’s supply and take what my doctor prescribed me but they won’t do their job and try to cover my medical expenses because this medication is not as cheap as they’d like it to be.
All right, not a big deal. Happens all the time. I just need them to call the doctor who’ll confirm that I really do need the medication he prescribed. A few days later, I come back to the pharmacy and find that while the insurance company did authorize the medication and the doctor confirmed that there was a real medical reason he recommended the medication he did and he’s not just scribbling random expensive brand names on his prescription pad for the hell of it, it will only cover $40. Why? There’s a deductable on my plan and before they’ll cover 80% of my medication as they say they will in their list of benefits, they want me to pay the whole deductible. If I want the medication that badly, I have to pony up $250 first. Or I could just comply with their wishes and get the pills they want me to take.
Now, I realize that you’re going to say. I need a better insurance plan. And that may be true. However, to get the kind of plans offered by mid-size and large businesses for their full time employees, I’d need to pay upwards of $600 a month. If you’re single and do a lot of freelance and independent work, that’s an awful lot of money to shell out. Without a spouse with a full time job and a good insurance plan, you’re likely to end up with relatively sporadic coverage that gouges you for up to 50% of every procedure’s cost until they get their deductible out of you. When you ask what you can do to counter the charges, you’re politely told that it would be much more beneficial for you to get on a group plan or get a much more expensive one.
Here’s the bottom line. If a doctor prescribes a medication based on his or her evaluation of your health concerns, you should get that medication without being gouged or blocked by an insurance company that doesn’t want to pay for something they think is too expensive. The only real way to get what you need without hassling with insurance companies and their immensely complex rules is to pay for it out of your own pocket. If you can afford to spend thousands and thousands of dollars on everything from prescriptions to tests, you can get some of the most advanced medical treatment any place you go. If you can’t, you’re stuck playing the insurance companies’ game.
I’ve been told by health insurance experts that I just need to know how to work around the system, how to appeal decisions and with who to stubbornly fight to get my way. My response is that this complexity is totally unnecessary. You should be able to get the treatment you need when you need it and the way your doctor recommends you get it. You shouldn’t have to outline plans to fight insurance company clerks who penalize you for being too expensive for their tastes. And quite honestly, if we have a major overhaul of healthcare in the United States, the last thing I’m afraid of is some random paper pusher making decisions about the level of care that will be covered when I go to the doctor. I’m already dealing with that, even when it comes to simple allergy medication prescribed to millions of people every year.
Seems that the message of the groups opposing healthcare reform is that when the paper pusher in question is from the government, you’re as good as dead. However, when he represents a company that makes more money by denying you a slightly more expensive but necessary medication and forces you to pay out of pocket for it, that’s magically a-ok through the miracle of the almighty “free market.”
You hit it on the head, Greg. While the town hall protestors are busy with their “no government in health care” thing, they don’t realize that, even if they are correct and government is about to put its nose between our doctors and ourselves, it couldn’t be any worse than that insurance company clerk currently making the calls.
What is particularly amazing is to see elder protesters (over 65) who already are on a government plan.
“I’ve been told by health insurance experts that I just need to know how to work around the system, how to appeal decisions and with who to fight to get my way.”
Isn’t that funny? I, a physician, have been told the exact same thing. “No, no, no, it’s not our *insurance* that’s the problem, *you* just need to figure out how to make it work. Now write me a ten page essay on why you prescribed this medication, so we can shred your argument and deny it anyway.”
I’m with you on this one.
Spot on piece Greg. Trust me things get worse, much worse for people with serious illnesses. I was eventually forced out of the private insurance market when my premiums climbed to over 800 bucks a month! Fortunately since I live in NYC i did have other options to me, something not available to the vast majorities of Americans.
“I’ve been told by health insurance experts that I just need to know how to work around the system, how to appeal decisions and with who to fight to get my way.”
That exactly is the problem with our health care system, the insurance companies are banking (literally) on the fact that most people don’t know how to work the system or are just too damn sick to do it.
Second attempt at trying to post this!
Spot on piece Greg. Trust me things get worse, much worse for people with serious illnesses. I was eventually forced out of the private insurance market when my premiums climbed to over 800 bucks a month! Fortunately since I live in NYC i did have other options to me, something not available to the vast majorities of Americans.
“I’ve been told by health insurance experts that I just need to know how to work around the system, how to appeal decisions and with who to fight to get my way.”
That exactly is the problem with our health care system, the insurance companies are banking (literally) on the fact that most people don’t know how to work the system or are just too damn sick to do it.
It’s hard to imagine the government doing a worse job than what’s being done already. Insurance companies are for-profit, so every claim paid out is money coming out of somebody’s bonus- clearly not the job “insurance” was intended for, which is pooling risks.
Let’s not get into the 60% of personal bankruptcies that represent acute and/or long-term illnesses by people WITH health insurance.
Though the flip side is the notion that insurance premiums are like admission to all-you-can-eat buffets- on average, your premiums have to be far greater than the average benefits received, or the whole thing collapses as soon as something really severe happens.
Precisely! It makes me sick listening to these “Grass Roots” protestors making accusations that the government will destroy health care. Well guess what? Health Care is already a thoroughly broken system for the average American. My conservative friend tries to argue that the choice of health care we so enjoy will be removed thanks to the governments nose in our business. I ask him, what choice is that? Do you have choices when it comes to your health care? We work for the same company, do you have some choices that I’m not aware of? I thought not. So the next argument is, I’m not going to be able to receive the same level of health care that I can afford now. Is that so? You are so wealthy that you can afford any procedure that our health care insurance company denies? No? I didn’t think so, we are distinctly middle class, and could hardly afford to foot our own bill if an incident occurs. I’m not exactly welcoming the government in with welcome arms, but seriously, promoting a for-profit system over an organization that is built to serve your interest?
For profit medicine is an abomination!
OK. I had to wait there a moment for the screaming to stop. The only way we are ever going to have a decent health care system in this country is to eliminate insurance companies altogether, and go with a generous, comprehensive single payer system in which all citizens and others legitimately in our country receive excellent care – unquestioned by anyone but your physician, and your personal injury attorney, all for a modest co-pay. The vulgar greed and “No Soup for You!” heartlessness of the insurance companies and the No-bots they employ would be a thing of the past. Good riddance!
But what about the money needed to fund innovation and future medical discoveries, you sputter. Still there. I didn’t imply no one connected to the health care “industry” should not make a profit. I simply don’t believe that at the personal level, like our author’s experience, health care should cost much of anything. A floor cost would be in order, so that even the least well-off amongst us would be guaranteed comprehensive, if not luxurious, care. That is what a single payer system does. Outside of those guidelines – and they need to be generous – private enterprise can go crazy, just like it does now. But won’t be able to stand between you and a reasonable life expectancy. Only the tobacco companies can do that!
thank you, Oregonmjw, I really think that with all the crazy debating and pundit rhetoric we’re all missing the point that something need’s to be done, the example that Greg presents is such a typical experience, that it’s almost to the point that no one even bats an eyelash.