On Monday, I wrote about Melanie Shouse, a passionate healthcare advocate who died partly due to of her insufficient health insurance. I wanted to share her story, but also to discuss the most egregious practices that the healthcare industry uses to deny Americans adequate and affordable care.
So, today I ask: how exactly can insurers defraud so openly? I found five major practices that are working in a perfectly orchestrated manner to steal our money and deny us medical care. They are as follows: the use of pre-existing conditions, gender rating, post-claims underwriting, retroactive policy rescission and the rewarding of employees for successful post-claims discovery.
Pre-existing conditions are used to block coverage either by making premiums and deductibles beyond reach financially, or as a justification to deny coverage at any price. No one ever asks why any pre-existing condition should serve as the roadblock to medical care. Unless you never become ill--all of us will eventually have a 'pre-existing condition.'
Gender rating is institutionalized discrimination against women by pricing premiums approximately 47% higher than those for men.
Post-claims underwriting and rescission go hand in hand. Post-claims underwriting occurs when an insurer investigates ancient medical records looking for any minor hint of a pre-existing condition, for the express purpose of canceling the policy when medical care is most needed. The cancellation is also known as policy rescission. The fraud lies in the fact that this investigation occurs after a policy has been written and accepted. Once someone has been 'rescinded', they are unable to obtain health coverage anywhere else. Wellpoint has a list of some 1400 different conditions that will trigger such post-claim investigation. Anecdotal accounts, including those recorded in official testimony before congressional committee chaired by Rep. Bart Stupak, documented accounts of patients losing coverage a few weeks before major medical procedures such as double mastectomy, due to some odd note in an old record which was misinterpreted by the clerk.
Insurance executives like Braly also regard post-claims underwriting and policy rescission necessary fraud prevention practices. Frankly, it is hard to imagine a sane person wanting to suffer from any life threatening illness so they can defraud insurance companies. Such thinking has many advocates for healthcare reform asking: why should anyone ever be denied medical care for legitimate medical need? Isn't medical care, regardless of any pre-existing condition, a human right.
These abusive practices have become so widespread that even recalcitrant members of the aristocratic US Senate, like Senator Feinstein, are now pushing for meaningful reform. In sworn testimony before the Senate...committee, Feinstein argued that the following specific reforms are critical: repeal of the McCarran-Ferguson Act (otherwise known as the anti-trust exemption); mandate DOJ (Department of Justice), the task of monitoring and pursuing criminal charges where appropriate against health insurers when they engage in price fixing, bid rigging, or market allocation; mandate the creation of a robust, non-profit public option which will accept anyone at affordable costs.
Feinstein further summarized that the most egregious abuses of the health insurance for-profit industry were directly traceable to the anti-trust exemption (McCarran-Ferguson Act), and ..."as a result, practices such as price fixing, bid rigging, and market allocation, prohibited by Federal law in every other industry, were left up to the states and their enforcement mechanisms."
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The president and congressional leaders claim they must have 60 votes in the Senate in order to pass these reforms, but that's not entirely true. The 60-vote criterion is mentioned in order to override a filibuster. These reforms could easily be passed with a simple majority, if the US Senate would actually conduct its business along constitutional precepts. Since we are stuck with the procedural filibuster that can table any substantive discussion, an alternative solution to the engineered deadlock is needed. The solution lies with the congressional procedure of 'reconciliation.' The CHIPPS or children's health insurance program was pushed through using this device. Senator Harry Reid does not need 60 votes to pass Feinstein's proposed reforms. Senator Harry Reid does not need the Republicans in some false gesture of 'bipartisanship.' He just needs some spine, a moral compass and 51 senate votes.
Building a system on gambling--which is the essence of insurance--is flawed both intellectually and morally. Melanie, and far too many others, paid the ultimate price. In Melanie's case, the delay engineered by her insurer cost her valuable time. We know that illnesses like cancer have a short shelf life. When treatment is delayed for even a brief window of time, it frequently costs the patient their life. Insurers like Wellpoint know this, and their delaying tactics could be considered the 'intent' to commit felony murder. If our government truly represented the people; Wellpoint , Angela Braly, Wellpoint CEO, and corporate counsel, would be facing felony murder charges--the same as if they had taken a gun to Melanie's head.
While it is admirable that the Senators pushing for 'reform' are finally 'seeing the light' regarding reforms such as a robust public option, and ending the anti-trust exemption, such reforms will not suffice unless criminal penalties are enforced against executives and their attorneys when they knowingly conspire to delay and deny treatment for life threatening illness.
Until these CEOs and the attorneys who labor to create the legal contrivances used to deny life saving medical care are held criminally liable for their actions, loopholes will be easily found.
The honorary awards in Melanie Shouse's name are definitely touching, but irrelevant. Melanie would have said so herself. If Melanie were here now, she would vehemently object to any memorial--instead, she would be challenging everyone to action. If you want to honor this courageous woman, then make her words a battle cry to action. Make this year the last year anyone dies from medical neglect, caused by the cold-blooded denial of care for life threatening illnesses. Make this issue so radioactive that no political or businessperson dares to deny medical care to anyone again.
Melanie Shouse was, like Mohandas Gandhi once said, "a small body of determined spirits" who, when fired "by an unquenchable faith in their mission can alter the course of history." In her honor, we must win this war, for our people, for our collective humanity. Melanie would accept nothing less.
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