What if your health insurance company says no?

I have insurance, but I'm also a "frequent flyer" with preexisting conditions. I've experienced substandard care

Published August 11, 2009 12:12PM (EDT)

Editor's note: Glenn Greenwald is on vacation this week. Pam Spaulding is guest-blogging today.

With the whole debate about healthcare reform swirling about, for the lay person, the level of misinformation, scare tactics and political posturing on both sides is tiresome. I discussed it earlier this month over at my blog ("Healthcare in the U.S. -- stop bickering and fix it"). I'll share a few snippets of that here.

Those of us who do have decent insurance are rightfully concerned that government mucking around in the system and playing politics with something that should be a right -- equal access to GOOD medical care for all -- is going to end up a big mess.

I'm not going to debate the merits of one plan or another here; I'm just looking at healthcare as a "frequent flyer" consumer with pre-existing conditions who sees doctors and specialists several times a year, and has adequate insurance that still has left me with long waits to see a specialist (3 months is not unheard of), and dealt with substandard care.

In our current system nearly everyone has horror stories about waiting for insurance to approve the most basic common sense things -- like one extra day in the hospital after a c-section, or trying to get a medication not yet in generic form that you and your doctor know works and the insurance company insists on a different generic substitute or you pay outright. The number and type of what I call "drive-by" surgeries, where they kick you to the curb a couple of hours after you've been opened up on the table is astonishing -- they wanted to do that for my gall bladder surgery and I begged to stay overnight because I've had complications after ambulatory surgery before that landed me back in the ER the next day. Thankfully it was approved, because I was right -- I developed a fever and had serious difficulties that I wouldn't have been able to manage at home.

But what if the insurance company had said no. That happens all the time. It happened to me several years ago, I wasn't able to stay overnight and went into the drive-through surgery; I developed a serious staph infection. It required a second surgery a couple of weeks later. A little time and attention would have saved everyone a lot of grief.

A lot of average people out there just want to see the basics laid out in a clear manner by the administration (and the other side, which, sadly and predictably, has nothing rational to offer given the gravity of the situation). The President has traveled the country, and now members of Congress are back home in their districts to address the concerns of people who do have coverage, and citizens wonder what will happen to employer-based, private plans with an overhaul of the system. Obviously we need to do something -- the system is broken even for those of us with coverage; it's painfully apparent. While getting care for the uninsured is a major problem, the urgency of addressing the under-insured, who think they are in the clear until the insurance company rejections start coming -- and the bills threaten to bankrupt them -- is clear.

However, I don't see how we can get to a public option any time soon with one side skittish and the other completely opposed to the point of acting like jackbooted thugs at town halls -- it would be optimal if the U.S. could do it right. We already do it with Medicare; the GOP seems to ignore it exists in its screams about "socialism", and I'm sure they wouldn't want it taken away from their grandmas and grandpas.

If you have surgery, it's always interesting to see the bill, just to look at the outrageous upcharging for the most basic supplies or administration of common OTC medications, you know, like the $150 bandage or $12 Tylenol. This bill was for an emergency room visit back in 2001 for a kidney stone attack; back then the deductible was a mere $75; today it would be $150; I imagine the whole bill today would double. Basically I spent a few hours on an IV getting fluids and morphine in the ER along with some bloodwork done, then sent home with painkillers.

Anyway, all of this is obviously pushing the cost of treating the uninsured, something the GOP seems to ignore when they say that leaving it all to market forces will work, including the creation of some kind of co-op where people can band together to obtain group coverage from a private insurance company. First, let's look at some pretty sobering numbers regarding the current state of affairs.

National Healthcare Spending

* In 2008, healthcare spending in the United States reached $2.4 trillion, and was projected to reach $3.1 trillion in 2012.1 Healthcare spending is projected to reach $4.3 trillion by 2016.1

* Healthcare spending is 4.3 times the amount spent on national defense.3

* In 2008, the United States will spend 17 percent of its gross domestic product (GDP) on healthcare. It is projected that the percentage will reach 20 percent by 2017.1

* Although nearly 46 million Americans are uninsured, the United States spends more on healthcare than other industrialized nations, and those countries provide health insurance to all their citizens.3

* Healthcare spending accounted for 10.9 percent of the GDP in Switzerland, 10.7 percent in Germany, 9.7 percent in Canada and 9.5 percent in France, according to the Organization for Economic Cooperation and Development.4

Employer and Employee Health Insurance Costs

* Premiums for employer-based health insurance rose by 5.0 percent in 2008. In 2007, small employers saw their premiums, on average, increase 5.5 percent. Firms with less than 24 workers, experienced an increase of 6.8 percent.2

* The annual premium that a health insurer charges an employer for a health plan covering a family of four averaged $12,700 in 2008. Workers contributed nearly $3,400, or 12 percent more than they did in 2007.2 The annual premiums for family coverage significantly eclipsed the gross earnings for a full-time, minimum-wage worker ($10,712).

* Workers are now paying $1,600 more in premiums annually for family coverage than they did in 1999.2

* Since 1999, employment-based health insurance premiums have increased 120 percent, compared to cumulative inflation of 44 percent and cumulative wage growth of 29 percent during the same period.2

* Health insurance expenses are the fastest growing cost component for employers. Unless something changes dramatically, health insurance costs will overtake profits by the end of 2008.5

* A recent study by Harvard University researchers found that the average out-of-pocket medical debt for those who filed for bankruptcy was $12,000. The study noted that 68 percent of those who filed for bankruptcy had health insurance. In addition, the study found that 50 percent of all bankruptcy filings were partly the result of medical expenses.9 Every 30 seconds in the United States someone files for bankruptcy in the aftermath of a serious health problem.

Fine, so let's do some magical thinking (the right wing knows an awful lot about that) and assume Congress and the President fold like a house of cards and we skip a public option, keep private and employer-based plans in place and do something like co-ops -- how do people in remote, less-populated areas do the latter effectively? These people are already screwed by lack of access to decent care and specialists. You can't cut across state lines to form a co-op because each state has its own laws governing how insurance companies operate. Let's say they figure all of this out this out and everyone in the U.S. (except undocumented people, which is a huge elephant in the room -- it's not as if these people are going away and won't ever need healthcare services again).

I want all of the members of Congress to answer one question: do they believe every person in the country is entitled to the same healthcare choices and offerings that they receive? If not, why not? It's too expensive" is not a legitimate answer.

That answer conveys a lot -- it says that our healthcare system should be a tiered level of care, some sort of meritocracy -- that some people are deserving of A+ quality care with all options and access available to them, and some are not. Those on the second and third tier (assuming the latter represents the current unemployed and uninsured) should be satisfied with something less, with fewer options, and limited access, lest they bleed the taxpayers dry. If this is the case, put that card on the table now so we can stop pretending there's an altruistic political endgame waiting for us out there.

* What does "holding costs down" really mean -- rationing services, improving digital recordkeeping, eliminated waste and duplication? Rationing or "streamlining" services is not unreasonable, but it's also not unreasonable to get an answer to what that looks like in real terms. Will your doctor be limited in the options of care available to someone based on cost not efficacy? What method of appeal would there be if there's a disagreement ? This question is relevant whether it is government-run or a private medical practice, because insurance companies already ration care now.

* How would a revamped system get more general practitioners and family physicians into the system? Right now there's little financial incentive to be a GP; and people out there know how hard it is to find a good one. Expensive specialists abound.

* Conversely, how would a reformed system funnel more doctors of any kind into rural areas, where -- third rail power up -- women's health services, for example, are limited?

Given our dog-eat-dog mentality here in the U.S., it's hard to imagine a public/private/co-op system emerging that will 1) hold down costs, and 2) provide first-class care in a timely manner to everyone that compares to the best private insurance out there now or what someone with deep pockets can buy. Polls show Americans want a universal healthcare that is comprehensive -- but no one wants to pay for it, of course. We can't have it both ways, and Congress knows that. To the layperson out there, all of the parties out there have a lot to lose and nothing to gain in an overhaul that is drenched in partisan politics that will result in compromise that satisfies no one.



By Pam Spaulding

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