As the health care debate continues in Washington and those of us who still hope for a public option (indeed a single-payer plan) find our dreams being crushed by the jaw-like machinery of the health insurance lobby, I'm forced to recall my personal saga with for-profit health insurance.
One thing I've learned through my ordeal is this: the health insurance industry functions like a gambling casino. Your health, indeed your life, has an odd attached to it. This is determined by actuarial charts. And according to said actuarial charts, at the outset anyway, I was a low risk customer: a "good gamble." I was in my late twenties, a vegetarian, a yoga practitioner, slim as a wafer, blood pressure of a trickling mountain spring, cholesterol of a plant. Sure, I had certain family histories, but nothing I needed to worry about at that age. The one problem I had was that, due to certain not uncommon digestive complaints and a routine office exam, a gastroenterologist had discovered a benign polyp in my sigmoid colon. This might have been unremarkable in a sixty or seventy year old, but at my age, it was something to watch. It was removed and I was told to have another colonoscopy within the next three to five years.
Fast forward a few years. I had moved, changed doctors, and bought a new insurance plan which I paid for out of pocket as a self-employed individual. I also had started to have some disturbing symptoms: gastrointestinal pain and worse than that, blood in my stool.
I went to my new doctor (let's call him Dr. Doolittle) and told him about my symptoms. I also told him about the polyp. I told him that I needed to have a colonoscopy. He scoffed at my concern. "People your age don't get polyps," he said.
I was taken aback by his seeming irritation. "I had a polyp," I told him. "Why would I lie?"
What I didn't realize was that the thought bubble above Dr. Doolittle's head might have read something like: How am I ever going to justify giving this test to her insurance company? She's too young for a routine colonoscopy. They are going to give me a hard time, chastise me for ordering an unnecessary test, maybe penalize me financially. What a drag.
Nevertheless, he grudgingly agreed to give it to me. And although I don't know what went on behind closed doors while he was trying to get the authorization, I can speculate based on what I've been told by doctor friends, things like: "That's the way it is now. I have to fight for every test." and "There's a lot of noise about unnecessary tests, but the reality is we can't perform necessary tests."
So in my speculation about what happened, I imagine that Dr. Doolittle had been peeved. The insurance company had given him a hard time and he was concerned about money. So when this renowned doctor, this attending physician at a prestigious teaching hospital performed the colonoscopy, he did it carelessly. He was angry at me for forcing his hand and he didn't really look. I remember that the procedure seemed to be over in the wink of an eye.
"You're a perfectly healthy young woman," he said with aplomb as he put away his instruments and removed his gloves. "You have a bleeding hemorrhoid. Next time you see blood in the toilet, ignore it. Now get out of here."
I had no reason not to believe him. Still slightly disoriented from the sedation, I was relieved that there was nothing seriously wrong with me. My thoughts turned to what I would eat for breakfast. I was given apple juice, dismissed and went about my merry way. And in fact, over the course of the next half year, my symptoms improved so much that I forgot all about it.
But then, almost suddenly, my symptoms returned. Now, however, believing I had a hemorrhoid -- the good Dr. Doolittle had looked inside, hadn't he? -- I tried countless home and natural remedies. I experimented with my diet: fiber, veggies, raw, cooked, macrobiotics. But after several more months, my symptoms became debilitating (and here I spare you the details.) I wanted another opinion so I chose a new doctor (let's call him Dr. Tulate.) By this time, I'd begun to suspect there was something seriously wrong. I wanted another colonoscopy. I asked him to repeat it.
Back to the thought bubble, this time Dr. Tulate's. Hmm (he might have thought looking at this now very skinny yoga woman) she just had a colonoscopy nine months ago. Her insurance company is really going to give me hell if I order another one.
"Now let me look at your tusche," he said as he stuck his gloved finger inside. "Nothing here. You're fine."
He sent me home with stool softeners.
I went back to him again and again. On the third or fourth visit, three months later, he finally agreed to order the test.
I had colorectal cancer. A big deadly tumor had been growing inside of me, undiagnosed for a year. It had breached the colonic wall and invaded my lymph nodes, threatening to spread to other organs and do what cancer does best: kill. I had surgery immediately. The tumor was so large it nearly obstructed my colon: a condition which could have caused sudden death from toxicity. I underwent six months of chemotherapy. I also prayed, meditated, studied anti-cancer diets and applied them, and visited a slew of spiritual healers. My friends, my family, even kindly acquaintances and strangers helped me through. My medical team was fantastic. Nine years later and I'm alive. I beat it; I lived and I am full of gratitude.
But in the process, unbeknownst to me, I had changed status in the eyes of my insurer. I had become a high risk customer, a "bad gamble." They studied their actuarial charts. They looked at the balance sheets. My premium payments probably did not exceed services rendered. I was a loss. A loser. And a future liability because, even though I am considered cured of that bout with cancer, I am higher risk for other cancers. They have done studies; there are statistics.
So one day, two years ago, seven years after my surgery, during another horrible life crisis, while my father was fighting for his life in the cardiac ICU, I found out that I had been terminated by my health insurance company. I was at the pharmacist's trying to fill a prescription for sedatives (I had been up all night at my dad's bedside and still couldn't fall asleep) when I was informed that my coverage had ended.
I was confused. Certainly there'd been an error. I called my insurer.
"No, you've been terminated," the customer service representative said with a bizarre satisfaction in her voice, almost as though I'd personally offended her.
"But why?" My mind flipped to an image of me and my bill paying routine: at the computer, sending off the payment. I'd paid my bill. I'd always paid my bill.
"Nonpayment," she said curtly.
"B...b...but that's impossible."
"You didn't pay your bill," she said with finality.
I realized I'd get nowhere with her, so I got off the phone. I went to my online banking page looking for the transaction. The payment had been requested, but hadn't gone through. But why?
After several more fruitless and aggravating conversations with several customer service reps, I got an answer: my insurer had changed its PO box number. Since I bank online (like almost everyone) I hadn't used the envelope provided, nor had I seen the notice they had supposedly sent out.
I breathed a sigh of relief -- my payment had gone to the wrong PO box, a misunderstanding which would certainly be swiftly rectified. I had been with them for years and despite the continued outrageous escalation of my premiums, I had paid them religiously. I thought I had been a good customer.
Boy, was I ever mistaken. After a lengthy appeal process, I was given my answer: the insurer wouldn't budge. No pleas, no begging, no tears could sway them. They had no pity. They didn't want me anymore; it was the final word.
Now this constituted a serious problem for me because, by the time I got my "rejection" letter, enough time had passed that given my pre-existing condition, another insurer would not only want nothing to do with me, but could legally deny me coverage. So after years of paying my premiums out of my own pocket and despite the desire to continue to do so, I found myself among the swelling ranks of uninsured Americans.
I was livid. Was suddenly changing the PO box a scam perpetrated on their customers to weed out as many "bad gambles" as they could? If I had been a "good gamble," let's say a 25 year old with no history of anything more serious than an ingrown toe nail, wouldn't they have just taken me back?
I was frightened. I was ineligible for any government program and no private insurer would take me. What if I had a recurrence? Would my parents have to sell their house and lose their entire retirement savings? What if I had an accident or something else unexpected happened? I felt like I was flailing about in treacherous waters with no life preserver, no flotation device, nothing.
Fortunately for me, I had friends (not in high places, but knowledgeable friends.) I feel lucky, especially when I recognize that not everyone in my position would have such friends or did have such friends. What happened to those who didn't have resources, who didn't know what to do, who just accepted the final judgment of the insurer like it was the word of God?
I called a lawyer friend who referred me to another lawyer who specialized in health insurance litigation. That very generous gentleman took time out of his day to give me free advice. He agreed with me that the sudden, inexplicable PO box change was probably an underhanded attempt to separate the wheat from the chaff, the "good gambles" from the "bad gambles." He told me exactly what to do: contact my public officials.
Now the operative word here is public. Get it. Public. The public official would be my friend. The private insurance company had already demonstrated they were not my friend. The public official wanted me to live and thrive and have coverage. The private company couldn't have cared less if I died in the gutter. I was a drain on their profits. I had committed the sin of becoming ill and become a "bad gamble."
As per the lawyer's advice, I called my state attorney general's office and with little ado and astounding efficiency, an extremely sympathetic staffer became my knight in shining armor. Within a week, my insurance was reinstated.
Two more years have gone by. My father passed after two lengthy stays in the cardiac ICU and a heart valve replacement surgery from which he never recovered. Medicare (public insurance) covered nearly the entirety of his treatment. My mother is widowed, but thankfully not bankrupt. I joined a professional union and was able to switch from an individual plan to a group plan under which I am much more protected by laws (laws made by public officials.) I know that in the final outcome, I am one of the fortunate. I know there are stories far worse than mine, stories of people who both had and didn't have insurance. Whose lack of insurance killed them or whose insurance (in withholding treatment) killed them. Who were terminated from their plans and hadn't known whom to turn to. So I ask you, America, who would you rather have determining what tests and treatments you are eligible to receive or whether you are eligible to be covered at all: a private company to whom you are nothing but a dot on an actuarial chart (a gamble good or bad) or a public agency whose policies you can influence? After my experiences, I know my answer.
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