Like other passengers on the RX Express, Tom Garbin hopes to get a prescription drug in Canada at a lower price than he would pay in California. In his case, it’s Neurontin, which helps alleviate pain from a hereditary foot disease. But Tom has another reason for going: He wants to use the bully pulpit the train provides to argue that the American health care system needs massive reform.
What sort of reform? Let Tom count the ways. From bulk purchasing to less expensive drugs to lower premiums to regulation to abuse of the "pre-existing condition" disqualification to, well, you name it. The system in the U.S., he says, is corrupt and, in some cases, criminal.
Tom’s intensity level, which has been high since he was nearly misdiagnosed literally into the grave a few years back, is at the orange alert level these days, to borrow a current federal color code. Tom just got back from his native Australia, where he was once again reminded that efficient governments can provide citizens with inexpensive, easy-to-get health care.
Tom’s accounts of the ease with which he received medical attention Down Under seem like science fiction. "You can walk into any doctor’s office," he says. "I got a blood panel done the next day. Then a glucose tolerance test." His doctor, a general practitioner, was apologetic when he spoke to Tom on a Thursday about follow up care. He couldn’t arrange it for Tom until the following Monday.
Can you imagine a patient in California getting in that quickly?
Tom says one of the chief reasons health care is so much easier to come by is the Australian system, which allows doctors, not bean counters, to be gatekeepers, deciding what medical care is needed.
When Tom isn’t extolling national health care, he is trying to keep up with endlessly increasing costs in his own health care coverage, which went up 63 percent between January and March. He just got another boost in August. "I want them to prove to me," he says, that the price jumps are justified. Insurers claim they need to raise rates to cover the cost of research and litigation, he notes. But Tom isn’t buying that story.
"They’re lying bastards," he says. Insurance companies won’t pay for experimental technologies, for one thing, and litigation is simply not behind the price increases. Greed and inefficiency are the culprits, he says.
Tom, a 61-year-old comedian from Garden Grove, has been keeping an eye on those who provide health care in California since 1999, when he was entertaining at a trade show. There was a health fair there and Tom had a PSA test, which measures for prostate cancer. That was on October 7. The doctor at the health fair told Tom that his test was abnormal and "suspicious for cancer." He recommended that Tom get a biopsy.
Then came a maddening series of visits to his health care plan doctors, who patted him on the wrist like a kindly aunt consoling a beloved niece whose boyfriend has dumped her. They ordered up an Ultrasound, which came back negative, then assured him that everything was just swell, not to worry about it and come back in a year.
Tom, they soon discovered, was not so easy to brush off. "I came here to get a biopsy," he told a health plan doctor as he slipped into his native Australian, "and I’m not leaving until I get a bloody biopsy."
The doctor ordered the biopsy on the condition that Tom leave him alone. The test, performed Dec. 21, came back positive. On Dec. 30, 10 weeks after the health fair diagnosis, the doctor told Tom he had prostate cancer and needed a radical prostatectomy within the next two months. Had Tom slunk away as they first suggested, he would not be telling his story, unless he found a way to communicate from beyond the grave.
But Tom’s struggles were not over. He researched, exhaustively, available therapies for treatment of prostate cancer. But the medical director of Affiliated Doctors of Orange County, which administered his health plan, would approve neither his choice of doctor nor the treatment, brachytherapy. Finally he relented and let Tom see his second choice, a doctor at UC Irvine, under two conditions: first, that Tom not tell anyone that he was being allowed to go out-of plan; and that the UC Irvine doctor accept Health Net‘s rates.
The radical retropubic prostatectomy was performed on March 31, 2000, at UCI Medical Center. It is a $35,000 operation and Tom paid his $1,000 co-pay. He later discovered that Health Net paid only $880 to UCI Medical. "Now UCI won’t touch any insurance company," Tom says.
Tom went to see his surgeon for follow up visits for two years, with no problems. Then one day his health plan refused a visit to the doctor who performed his surgery. Since then the plan has denied other payments, including $20 office visits. Tom is paying for his own PSA tests.
"I believe that money is not the issue here," Tom says. "My premiums are a whopping $4,536 a year and they can’t approve a $20 office visit?" Tom is not buying that argument, or the providers’ standard line that health care costs have gone up and are simply being passed on to customers. He thinks that, like many people over 55 in health care plans, he is being squeezed out.
"Between 60 and 65 (when Medicare kicks in) is no man’s land," Tom says. "No insurance company is going to touch you if you’re 60." He believes health insurers conspire to keep older people with pre-existing conditions on a blacklist.
Meanwhile, Tom’s costs continue to rise. Providers’ efforts to deny treatment, combined with their profiteering, is a rancid combination, Tom believes. "You have to fight them tooth and nail for everything you have done, and they keep raising their rates and taking away benefits."