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.
Follow Ester Amy Fischer on Twitter: www.twitter.com/esteramyfischer
I have learned one thing, however, and that is when one is a former Advanced Nurse Practitioner and that silly RN Case Manager calls me about something, I have four or five studies and the opinions of several of the most heralded physicians in the speciality and copies of the usual and customary manner in which one of the renowned specialty hospitals in the country would treat the problem. Yes, it does help to be a former Medical Professional myself, but use the internet and call the assistance lines at said facilities, ask for the info and tell them you need it to club your insurance company and they will fire it out to you, as they hate insurance companies as much as we do. I then use my nicer than nice approach with the insurance, but if they try stupid with me, I then suggest in a very calm voice, that we need to discuss it it face to face, in order to understnd fully. Usually, within an hour, or while we are on the phone, I get the permission.
Insurance medicine is only practiced in the USA and it's characteristics are punishing doctors by dropping them from the plans if they follow best patient care, dropping patients if they get ill, and pulling every underhanded trick in the book, legal or illegal and seeing who has the energy or time to fight them.
More doctors are getting sick of it and not accepting insurance anymore. I know this because my clinic and several of our colleagues are doing the same thing. Frankly it was costing us more money to get paid than we got paid for insurance patients. We have 1/3 the costs now and spend more time with patients and give them much better care at 1/3 the cost to the patient.
If the US does not get private insurance (which is another way to describe armed rape with intent to kill IMHO) out of health care and soon then we will never fully recover economically.
The sad truth? My condition should have been a huge red flag immediately, or at least by the second incident. A healthy 32-year-old non-asthmatic doesn't spontaneously go into emergency respiratory arrest without an underlying cause.
Thank you for sharing this.
This accounts for up to 50% of the population, which is, in any statistical universe, a good way to jigger the results. Stay in the EU buddy.
I shudder to think that your case is not a sole one, but one that is lived times a million all across the USA.
In my view it is immoral for a modern nation NOT to provide health care security for all citizens.
It is not a system that is served by free enterprise. It is a basic service that is a foundation for the health of companies in the free enterprise system and individuals in the country. Most developed economies recognize this and have much, much better levels of health in their countries. It is time for us to wake-up if we are going to compete globally.
As someone who has a chronic health condition, AND as someone who works in hospital administration (specifically in oncology care) who has lived in both Europe and America, America's health care system is a joke, a travesty. If I had to "choose" between being sick in Europe and being sick in America, I pick Europe, no hesitation.
For years, my husband and I paid more per month for our lousy 30% copay health insurance than we did for our rent. A difficult pregnancy left us with a $23,000+ debt, which we paid in monthly installments over the next four years. By that time my husband had a job with health bennies, but we had very little savings. I was diagnosed with cancer when my daughter was 5. My HMO refused to authorize a biopsy until the cancer in my lymph nodes had spread and grown to *visible* lumps in my neck. The treatment (even with insurance) left us bankrupt. My husband has had many opportunities to move up and on in his career, but he had to remain in his current position because we can't risk losing his health insurance. If he dies or leaves me, I'll never have health insurance again.
How is it even possible for anyone to claim that American health care is better than the socialized European models? Objections to Obama's plan are just kneejerk ditto-head ignorance.
Oh, and Placebo darling, when you're faced with the choice between chemo and death, you're more than welcome to let nature take its course. I was not about to go so gently. Viva la chemo!
I don't think that Placebo was making a judgement about your choice of treatment but you should know a few things about chemo.
I should disclose that I own a primary care clinic that does allopathic and alternative care in an integrated manner with it all being overseen by a medical director with research background. I should also disclose that when my mom had cancer we helped her set up both tradtional chemo adjuncted by alternative treatments. Her MD attributes her ND (naturopathic doctor) with extending her life expectancy and quality of life by 4 years longer than anyone expected, so I am not exactly a carrot chewing, tree hugging reactionary.
However, you should know that chemo is not the be all and end all of cancer treatments. For example, since it's inception as a highly experimental treatment, it has never been studied in a pure double blind study against control neutrals or against other treatments. Which is kind of like comparing one little league baseball player against another and then making conclusions about the yankee's roster.
The decision doesn't have to be all or nothing, chemo or death.
Just my 2 cents. Glad you are still with us. Now let's go out together and get single payer.
My insurance company dropped me the day after I was diagnosed due to a paperwork error. Inner healing is an important part of the cancer experience, but if I had not corralled my "inner lawyer" I would be dead by now. I learned how to become a powerful advocate for myself, busting down the door of the healthcare system and fighting for what I needed to stay alive.
In the United States, young adult cancer is political. Juice all the kale you want but if you can't get a PET scan too monitor the size of your tumor it doesn't make much of a difference. Meet with your representative this August and demand a public option.
Thanks for the great article Ester.
Kairol Rosenthal
blog: http://everythingchangesbook.com/
Let's place the blame where it belongs, with the insurance companies. It is the insurance companies who are denying any methods of tracking treatment outcomes (such as PET) in order to reap record profits
I am sorry to hear of your ordeal but happy that you seem to have beaten it:)
I think that they use this excuse...you forgot your payment, as an easy way to purge, happened to me with COBRA. And of course, now I pay a heck of a lot each month with Blue Cross.
I think that we, as cancer survivors and members of their families learn a heck of a lot about cancer and health insurers much of it not nice information at all.
Best wishes!
Then what do you suggest?
Probably thinks if people just need to be "responsible" and set up medical savings accounts to meet these high costs. And if we could stop those pesky lawsuits for malpractice (such as the author of this piece experienced TWICE) then costs would come down.
Easy peasy.