A Lesson in Insurance

OK class, today we're going to explore some of the myths and facts about Health Care Reform and Insurance in America.

There is quite a lot of rhetoric and lying going on by Republicans and Insurance industry-backed "Tea Partiers." These lies and distortions rely on an important fact of life in America: No one understands their own health insurance.

It's true, most of the people with health insurance in America fumble blindly in the dark hoping they hit the right combination of paperwork to make the Insurance slot machine pay that bill.

So, let's look at the lies and the realities of having insurance in America, shall we?

First, please locate your insurance card from your wallet or purse. Now, look carefully at that card because we're going to be looking for some key terms on it.

Myth: Health Care Reform will mean that you will be assigned a doctor and will no longer be able to choose what doctor you wish to see. In America, we are free to choose any doctor we want!

Fact: Refer to your insurance card. Do you see two different "co-pays" listed for "in network" and "out of network"? Do you see the magic letters "HMO" or "PPO"? If so, you are not free to choose any doctor you wish. You probably received a list of "network" doctors when you signed up. You may have even been required to choose a doctor at that time as your "primary care" doctor from that list. You will not be able to see "any" doctor you want unless you're willing to pay out of pocket. The same holds true for hospitals, pharmacies, and even durable medical equipment suppliers.

If you change employers or if your employer changes insurance you will be provided with a different Preferred Provider list. If your current doctor, hospital or pharmacy isn't on it then you'll be forced by your INSURANCE COMPANY to change. You will not get to say "No, I don't want to change." unless you're willing to pay higher fees or forgo insurance reimbursement completely.

Real life horror story:
On February 7, 2008 our family was shattered when we lost our one and only son Clinton Ron Walker at the age of 17.

For over a year, Clinton had suffered strange seizures that would rack his body and cause him to run, jump and moan for over 2 or 3 minutes. He went to the pediatrician who wanted to send him to a special clinic but my insurance AETNA denied our request.

After months of visiting several doctors, and receiving a misdiagnoses of panic attacks, our pediatrician found a new neurologist who was set to take on Clinton's case using my husbands' insurance plan.

The week that he was schedule to see the new doctor Clinton died.

We later learned he had a heart defect that caused his seizures. Had our insurance allowed us to take him to the special clinic where there was a cardiologist on staff we believe he could have been saved and alive today. Please help us get insurance companies to let us see a variety of health care providers for our children. -- Candace Walker, Newnan GA

Myth: Health Care Reform will put in bureaucrat in charge of your healthcare and he/she will tell your doctor what drugs they can prescribe and what treatments are necessary. Health Insurers would never dabble in the Patient-Doctor relationship.

Fact: If you have insurance your doctor has very little latitude in his treatment options. Again, did you receive a "formulary" when you got your health insurance documents from your employer? That is the list of all the acceptable drugs your insurance company allows your doctor to prescribe. If your doctor wants to prescribe a drug that isn't on the list you will have to file an "appeal" and wait weeks or months for the insurance company to (usually) deny it or you will have to pay for the medication out of your own pocket regardless of cost. Even if the drug is covered, it might be a "Tier 1" or a "Tier 2" or a "Tier 3" drug. Depending on that classification you will have to pay more for the drug. Often the highest priced drugs are the most vital for the preservation of life. These drugs are often not covered by insurance or are covered at markedly reduced rates making them impossible for ordinary patients to afford.

In addition, the insurer often decides exactly what treatment is "appropriate" for your illness based on their own bottom line. What you and your doctor may feel is appropriate, your insurer might think is inappropriate, particularly if it is expensive. This is particularly true of alternative therapies and adjunctive therapies that are never covered by health insurance.

Real life horror story:
Blue Shield of California is denying me life-saving and life-prolonging treatments. I am 36 years old and have Blue Shield HMO health insurance coverage through my employer.
In January 2009, I was diagnosed with metastatic (stage 4) breast cancer. When discovered, it had already spread to my bones, lungs, liver, and brain. My doctors prescribed a medication that targets and removes the cancer throughout the body like a "smart bomb"; however Blue Shield of California denied coverage of my doctors' recommended treatment. Blue Shield also denied a radiation procedure that would target and remove the two lesions in my brain.
In both cases, Blue Shield denied the original requests and subsequent appeals I filed on the grounds that the treatments are not a medical necessity. I have learned that insurance companies will use "medical necessity" as an excuse to not cover treatment when it appears that the patient is "too sick" (read: not worth it). -- Megan Jones Altadena, CA

Myth: Insurance is readily available as long as you're willing to work. If you are unemployed then you're covered by Medicaid.

Fact: That's one of the biggest lies spread by heartless and ignorant people. In fact, it's a lie I heard just the other week from an old friend in nursing who should know better. Although she's a great nurse, hearing her say this has made me question whether I would ever want her to give me or a loved one care because it showed amazing hubris.

The reality is that even if you have insurance with your employer, there is no guarantee you will be able to get insurance if you change employers should you have a "pre-existing condition." Likewise, in many states, if you are unemployed you are not eligible for Medicaid unless you have children or are disabled. This means that someone who loses their job because of an illness also loses their insurance. Once they lose their insurance the illness can no longer be treated and worsens.

My real life horror story:
This was exactly what happened to me before my liver transplant. I began having strange symptoms that eventually caused me to have to take a leave of absence from work. When I returned to work it was only part time and my insurance premiums tripled. In fact, I was paying all but $5 of my weekly wages for insurance! After a few weeks it was obvious I would not be able to continue working and had to leave my job completely or be fired. I lost my insurance.

For months I could not see a doctor about my worsening symptoms because we could not afford the cost of visits and the numerous tests. It was not until I was in complete liver failure and taken to a hospital that I was diagnosed with liver disease. It was only through the efforts of a social worker and medicaid specialist on staff that I finally was listed as disabled and placed on Medicaid so I could get a transplant. That process took almost 3 months.

Now, I am stuck in limbo. If I return to work full time I will not be covered by insurance for my check-ups and frequent lab tests to make sure I am not rejecting my liver. I will not be provided with the hugely expensive drugs I must take every day to prevent rejection of the organ. I will not be able to get surgery to treat incisional hernias that seem to develop like clockwork because of the poor state of my abdominal muscles before my transplant.
Myth: Health Care Reform will cause huge "waiting lists" for vital procedures. With private insurance corporations, there is never a wait. You just go to the doctor and get what you need!

Fact: Insurance companies thrive on the delay of care. Does your insurance packet mention you must be "pre-approved" for certain tests, medications, procedures, or surgeries? If so, welcome to the waiting list for care!

A pre-approval straddles the gulf between rationing care and insurance clerks prescribing care. In the pre-approval process, the insurance company wants to do two things. First, they want to put you off getting whatever treatment is needed as long as possible. After all, maybe you'll decide not to have it or maybe you'll die. Either way, it helps the bottom line. Second, they want every opportunity to deny expensive treatments. This means that your "pre-approval" is likely to be denied. Even if it is not, you can expect them to delay as long as possible with various forms required from your already overworked doctor. These forms will then be "reviewed" by a board who will decide if your own doctor knows what he's doing. Sound like the nightmare spun by the Insurance Company Tea Partiers yet? It's an old tactic called transference. They are actually telling you what they do as corporate policy but pretending it will be what happens under a government-sponsored public option!

Real life horror story:
For profit healthcare killed my wife. On my birthday, August 5, 2008, my wife and I went to see a cardiologist. She was told that she would have to wait seven days to get approval from her insurance company to proceed with testing. Stress testing and radioactive imaging were performed. Despite her family history and risk factors no additional test were run. On September 7, 2008 Becky passed away from Sudden Cardiac Arrest Syndrome. - John, Nashville TN

Myth: If you work, you get health insurance from your company. So don't worry about it, you don't need a government option.

Fact: In Arizona alone, 60% of small businesses do not offer any health insurance coverage for their employees. This means that the "backbone of the economy" (to quote Republicans) is made up of uninsured lower-wage workers who cannot afford to purchase health insurance on their own and whose employers refuse to provide help for them.

Tax credits or rebates are not helpful for lower income people because it requires that they still pay out of pocket and wait for a reimbursement at some point in the future. This means that if they don't have an extra few thousand to buy a policy in the first place, they won't be able to get the credit down the road. A convenient oversight for rich Republicans to whom a few thousand is something spent on lunch.

Even in cases where plans are available through employers, there are often minimum hour requirements meaning those employees who fall even an hour short of the cut-off are not eligible.

Real life horror story:
I have not had healthcare in over 3 years I am a temp at my job and they do not provide benefits. However, they say I am not eligible for Medicaid. In no way can I afford to pay for healthcare at the prices they charge.
I am a 35 year old woman with health issues who cannot even see a doctor. I was diagnosed with Fibroids after suffering a miscarriage I had to stay in the hospital and have a D&C performed with no insurance the bill was about 5k.
I can't afford to pay so now I'm in collections. On top of that never have been able to have a follow up to see if my condition has progressed. I have so many aches and pains and yet I have to choose between my health and paying my rent of feeding my kids.
I have worked hard all my life and due to the economy and rough times am stuck in a job that will not provide me benefits but I need to work to support my family. There is a history of ovarian cancer in my family but I can't even afford to get a check-up. It scares me because my family depends on me and if something happen I wouldn't know until its too late. I hope and pray every day for affordable healthcare just so I can take care of myself. - Lissette, NY

I urge you to visit the Health Care Action Center and read the hundreds of stories about our broken system and how corporate insurance is grinding up our citizens for profit. The stories on the site are stunning and heartbreaking. In fact, I think the answer to the Insurance Company Teabaggers' screaming would be to read those stories one after the other and ignore their screams. After all, are they getting employer-based coverage from the insurance companies paying them to protest in the streets?

Class dismissed.