Like it or not, Health Care is broken

Who the hell am I to write about healthcare?  I have by most standards, excellent insurance coverage provided by my wife’s employer.  Before that, I was able to insure through the same company with a small business policy, and before that I had insurance coverage that was (partially) paid for by an employer.

My only real problem came with some “in between” times, where I learned the perils of Cobra coverage (which is supposedly designed to take care of those specific times), as well as the dreaded, “pre-existing condition” issues that arise (more on that as we go along).

So yes, I am fortunate enough to have “good” coverage, and lucky enough that my family has no “factors” that render them “uninsurable.”  But it is just that.  Lucky.  And as with anything else, it worries me that it is only a matter of time until my luck runs out, and I find myself in a position, like so many others, either unable to afford, or unable to get (at any price) insurance because somebody has some condition that blackballs us because some statistician has determined that a particular condition is “too risky” for them to cover at all.

Now let me state up front that I am in no way a fan of Michael Moore.  I find that unfortunately, as much as he wants to make a good point (as with the recently released, “Sicko”) that his showmanship is a bit too much, and that the message that he is trying to get across gets lost because of his overboard tactics.  That being said, his timing and topics are often right on, and that is certainly the case with the healthcare in this country.

If you think health care in this country is not a problem, then either you are a major stockholder in one of the Health Insurance Companies,  are being paid off by the or are just not paying attention.  Because even if you have insurance, you almost have to be forcibly ignorant not to see what is going on.  How many valid claims do you have to resubmit, explain, or challenge to get paid because they seem to be almost randomly denied.  I say randomly, because at a glance there is most likely no obvious and legitimate reason for it be denied.  And even trying to ascertain the actual reason for the denial can be a challenge as it is cloaked behind codes, and asterisks and run-on sentence explanations that seem to say completely different things within the same sentence.

Despite having continuous coverage that dates back to somewhere in the early 90’s (the last time both TheWife and I had employers that didn’t provide coverage at the same time), we have more times than I can count, had to battle with “pre-existing conditions” issues.  I’ll give you a few personal examples.

The first is  my own, and one that can be arugued either way.  Back in the early 80’s I was working as an EMT with an ambulance company (that ironically did not offer health insurance).  While on the job one day, I got caught in gunfire in a not very good neighborhood, and got hit in the head.  The bullet (fortunately) did not penetrate my skull, but was embeded below my scalp.  The insurance company that handled my workman’s compensation claim decided that since there was nothing life threatening about the bullet, they denied the hospital the ability to perform surgery to remove it.

Fast forward 20 years, I still have that projectile embedded there, however now a doctor I have gone to says that it really should not have been allowed to remain considering that many projectiles are made from (or contain) lead, and that it would be wise to have it removed.  So, we send the paperwork in to my insurance company now.  Denied.  Pre-existing condition.  Which, by technicality is true, but it is only now that the actual “risk” is being determined.  Worse, anything that I may develop later because of it, would also be denied. So, really it comes down to whether or not I am willing to pay for it myself.

Less arguable is the situation with LatteGirl.  She was born with the unfortunate circumstance of being the child of a mother that has both allergies and asthma, and a father that also had major allergy problems as a kid.  But in her case, she has not been without insurance basically since the day she was born.  A “Pre-existing” condition clause on a chronic condition is normally done to deny claims within the first 6 months of new insurance, where none existed before (presumably to avoid people buying insurance only when they find out that they have something serious that needs immediate attention, and then not staying with the company long enough for them to make up in premiums what they have laid out in coverage). But since LatteGirl has not had any lapses in coverage, this should not apply.  And in actuality doesn’t.  But that doesn’t stop them from denying claims made for both doctors appointments and denying prescription coverage on a routine basis.  I then have to spend hours (and a few times days) on the phone with Customer Service Reps, and their supervisors, before I (once again) have to fax over proof of previous coverage to once again get coverage reinstated.  Only to have to play the same game a few months later (you would think that this stuff would be “on file” eventually wouldn’t you).

Finally, and what may be the dumbest of examples.  My mother has cancer.  She has thus far outlived all projections, and has been doing quite well on a chemotherapy regiment, that has been keeping the tumors at bay.  Not improving her situation, but actually keeping it from getting worse for the past three years now.  Of course, as most are aware, the drawback to chemotherapy is, severe nausea.  So her physician prescribed medication that helps deal with this.  However, the medication is supposed to be for “short term” use only, and thus since she does not have a “medical condition” that warrants the continued use of the drug (”side effect” is not a medical condition apparently), every month we have to challenge the ruling and justify the use.  You would think that at some point it would be cheaper to actually keep the previous rulings (again) on-file rather than having to repeat the same process ad nauseum.   But it goes back to what I said earlier about them seemingly doing this randomly in hopes that people get too tired or just give up fighting so that they don’t have to pay.

We have these kinds of issues, and we have health insurance.  I can’t imagine the nightmare that those without have to deal with.  Or worse (I think), not being able to get insurance because a spouse or child has a condition that they don’t want to cover. Something like 1 in 150 children every year are now diagnosed somewhere along the Autism Disorder Spectrum (Based on prevalence statistics from the Centers for Disease Control and Prevention (2007)).  I am not going to debate, nor is this about whether something belongs in that “Spectrum” but the fact is that most of these kids (and or their parents) will have problems with insurance at some point.

It is easy to sit back and say, “There but for the grace of god go I.”  But that solves nothing.  And what happens if unfortunately at some point you are not so “graced” and find yourself in that position?  It is a serious problem that needs serious solutions.  Now.  Not eventually.  Not when it is a “critical problem.”  Because, if you run into one of these issues… your perspective on what is critical, will suddenly and drastically change.

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