The debate over health care reform too often comes down to a shorthand of insuring the uninsured. But even having an insurance policy isn't the same as being able to get health care. Karen Tumulty, a health reporter for Time, tells us what happened to her brother when kidney failure struck -- a maze of debt and rejection that threatened his life, even though he thought he'd had insurance for six years. The story is full of reasons why private insurance companies can't be allowed to dictate national health policy.
The first is that insurance companies will push policies with very high deductibles to make their policies look cheap. The statistics tell us that high deductibles mean people delay care, almost as if they were uninsured. Here's the human face, from Tumulty's story abut her 54-year-old brother:
Looking back over the past three years, my older brother Patrick now understands the meaning of his increasingly frequent bouts of fatigue, his fluctuating appetite and the fact that his blood pressure had crept up to 150/90. But Pat had always put off going to the doctor until he had to. Having bought health insurance that carried a $2,500 deductible, he knew he would have to pay for a checkup himself. That is no small consideration for someone who makes $9 an hour, as my brother did in his job as an administrative assistant for a lighting firm in San Antonio. He also struggles with Asperger's syndrome, a disorder sometimes described as high-functioning autism. Pat can multiply three-digit numbers in his head with ease, but he has trouble accepting the unfamiliar and adjusting to the unforeseen.
The unforeseen was exactly what turned up when Pat went in for a physical on Nov. 30, 2007, his first in five years. The doctor found high levels of blood and protein in his urine, results that were confirmed in another round of tests in December. Soon after that, Pat discovered that his urine had turned brown and foamy. In the middle of all this, he was laid off from his job ... Finally, last July my brother's doctor insisted that he see a specialist, who quickly ordered a biopsy. That's when Pat, who is now 54, learned that his kidneys were failing.
At least, thought Tumulty, he's insured. Just for getting a diagnosis, Pat had been billed $14,000.
Pat had been faithfully paying premiums to Assurant Health, buying a series of six-month medical policies, one after the other, always hoping he would soon find a job that would include health coverage. Until that happened, "unexpected illnesses and accidents happen every day, and the resulting medical bills can be disastrous," Assurant's website warned. "Safeguard your financial future with Short Term Medical temporary insurance. It provides the peace of mind and health care access you need at a price you can afford."
But there was a loophole:
Pat's decision to save some money by buying short-term insurance was a big mistake, says Karen Pollitz, project director of Georgetown University's Health Policy Institute and a leading expert on the individual-insurance market. "These short-term policies are a joke," she says. "Nobody should ever buy them. It is false security that is being sold. It's junk."
That's because diagnosing and treating an illness may not fall neatly into six-month increments. While Pat had been continuously covered since 2002 by the same company, Assurant Health, each successive policy treated him as a brand-new customer. In looking back over Pat's medical records, the company noticed test results from December, eight months earlier. Though Pat's doctors didn't determine the precise cause of the problem until the following July, his kidney disease was nonetheless judged a "pre-existing condition" - meaning his insurance wouldn't cover it, since he was now under a different six-month policy from the one he had when he got those first tests.
And of course, the insurance salesmen had never mentioned this to Pat, even as he steadily paid his premiums for six years. And of course, no one at the insurance company went back and looked at his medical records until he submitted one expensive claim and might actually cost them money. This isn't just a practice of some rogue company: Blue Cross and other companies in California illegally cancelled thousands of policies through such "post-claims review" of medical records.
The medical system also showed itself at its worst, as Pat was billed at five or six time the discounted insurance rate for tests, medications, radiology.
Pat's great luck was having Karen for a sister. Her years of expertise with health care policy made her able to stitch together free or sliding-scale care to keep Pat in drug treatment and off dialysis for a while. Ultimately, she made the insurance company pay up by filing a protest through the state--and identifying herself as a journalist. I wonder if an average Joe would have the same luck, without the threat of shame and exposure to hold over the bad corporation's head.
If the insurance company hadn't found an excuse to deny payment altogether, you can also be sure it would have used delay and other kinds of denial to its advantage, perhaps by classifying his expensive kidney drug as "experimental."
This is the problem the U.S. faces if it lets the insurance industry be a "partner" in health reform, with every American forced to buy their products. The insurers are already demanding that Americans not be offered even an option to join Medicare, because it would make an "unlevel playing field" in which a "public option" like Medicare would outcompete the private insurers on both cost and satisfaction. But that's precisely why we should want to open Medicare to all. Make insurance companies reform or die.
It's not like insurance companies show any mercy to their custormers, like Pat. Without competition from a public plan, they'll keep creating new loopholes that deny care, foster inefficiency and keep shareholders happy at any cost to national health.