Wednesday, March 18, 2009

The Health-Care Crisis Hits Home

I try not to get all preachy and stuff, but when I heard the podcast version of this story at the gym I thought, this indeed is the best thing on the interwebs today. And it's important. I found the print version, and tried to pick the best exerpts, but really, you should  just read the whole thing.  // 

The Health-Care Crisis Hits Home is a Time article by Karen Tumulty.  Karen has written extensively about health care, but recently, the problem has struck very close to home: her brother Pat was diagnosed with kidney failure.

"For six years — since losing the last job he had that provided medical coverage — 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...

Kidney failure would seem to be one of those disastrous 'unexpected illnesses' that Pat thought he was insuring himself against. But apparently he was wrong. When my mother, panicked, called to tell me that the insurance company was refusing to pay Pat's claims, I told her not to worry; bureaucratic mix-up, I assumed. I said I'd take care of it, bringing to bear my 15 years of experience covering health policy, sitting through endless congressional hearings on the subject and even moderating a presidential candidates' forum on the issue.

Confident of my abilities to sort this out or at least find the right person to fix the problem, I made some calls to the company. I got nowhere. That's when I realized that the national crisis I'd written so much about had just hit home."


Pat represents the shadow problem facing an additional 25 million people who spend more than 10% of their income on out-of-pocket medical costs. They are the underinsured, who may be all the more vulnerable because, until a health catastrophe hits, they're often blind to the danger they're in. In a 2005 Harvard University study of more than 1,700 bankruptcies across the country, researchers found that medical problems were behind half of them — and three-quarters of those bankrupt people actually had health insurance.


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.' 


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. 


There was at least one thing we didn't have to worry about, Haile assured me. Pat's kidney doctor, Peter Smolens, would keep treating him even if he couldn't pay. Smolens, a thin, soft-spoken man, later told me that about 10% of his patients have inadequate insurance or none at all. He has agonized with some as they struggled with hard choices, like whether to have a hospital biopsy or pay their mortgage. As a physician, he said, 'you just see them. You know you're not going to get paid.'


A paradox of medical costs is that people who can least afford them — the uninsured — end up being charged the most. Insurance companies, with large numbers of customers, have the financial muscle to negotiate low rates from health-care providers; individuals do not. Whereas insured patients would have been charged about $900 by the hospital that performed Pat's biopsy (and pay only a small fraction of that out of their own pocket), Pat's bill was $7,756. For lab work — and there was a lot of it — he was being charged as much as six times the price an insurance company would pay. One pathology lab's bill alone was $3,290.


Pat's kidney function, which was 48% when Smolens first saw him last summer, has fallen to between 35% and 40%. And there are now outward, obvious signs of Pat's illness: he is lethargic, his eyes are puffy, and his lower legs and ankles are swollen to twice their normal size.

...the average cost of dialysis treatments in this country is $60,000 per year plus. There's another paradox: if Pat gets sick enough to need dialysis, as he well may, the Federal Government will pick up those staggering costs under the Medicare program for end-stage renal disease. But until that point is reached — and the goal is to keep him from getting there — his options are limited. Now that he is sick, it would be nearly impossible for him to purchase another insurance policy on the individual market. Since he lives independently and holds a job, it would be difficult for him to qualify for Social Security disability benefits. brother would have to wait 12 months to join with a pre- existing condition, under the state's 'adverse selection' regulations that seek to prevent uninsured people from joining the pool only after they get sick.


As this country prepares to engage in its first serious debate over comprehensive health-care reform in 15 years, there are two leading approaches to covering the 45 million uninsured and reining in costs. One, which President Barack Obama is putting forward, would force more employers to offer coverage to their workers, with subsidies and other incentives to make it more affordable. The other, advocated by Republicans (including Senator John McCain in the recent presidential campaign), would take away some of the tax advantages that come with getting coverage at work and thereby put many Americans who are now covered by their employers into the marketplace on their own. The idea is that they would be the ones best equipped to decide which plan suits their individual needs.


Pat's experience suggests it is difficult for an individual to make such judgments. And the existing market for these kinds of policies leaves a lot to be desired. A 2006 Commonwealth Fund study found that only 1 in 10 people who shopped for insurance in the individual market ended up buying a policy. Most of the others couldn't find the coverage they needed at a price they could afford.

The individual health-care consumer has very little power or information. Still, it turns out that there are ways to fight back. As I was reporting my brother's story, I discovered something about Pat's former insurance company: last May, insurance regulators in Connecticut imposed a record $2.1 million in penalties on two Assurant subsidiaries for allegedly engaging unfairly in a practice called postclaims underwriting — combing through short-term policyholders' medical records to find pretexts to deny their claims or rescind their policies. In one case, a woman whose non-Hodgkin's lymphoma was diagnosed in 2005 was denied coverage because she had told her doctor on a previous visit that she was feeling tired. Assurant agreed to pay the fine but admitted no wrongdoing.

So I contacted the Texas Department of Insurance, identifying myself as both the sister of an aggrieved policyholder and a journalist. Officials there suggested that Pat file a complaint against the company. Each year the department receives as many as 11,000 complaints and manages to get $12 million to $13 million back for consumers, Audrey Selden, the department's consumer-protection chief, told me. 'It is important to complain.'

And it's easy too. It took Pat and me less than 10 minutes to fill out the complaint form over the Internet. That was Jan. 14, 2009. On Feb. 9, we had an answer: Assurant maintained that it had done nothing wrong and that Pat should never have relied on short-term coverage over a long period. But given 'the extraordinary circumstances involved,' the company agreed to pay his claims from last year, when the policy was still in force. (Pat canceled it on Aug. 22, 2008.) Those extraordinary circumstances, I assume, included the fact that the state insurance department was sniffing around."

There is a very interesting audio story on the same topic by WHYY's Fresh Air. Enjoy!

(From Fresh Air )

PS: Happy birthday to my dad on St. Paddy's Day. 

1 comment:

Guy Danus said...

ahhh wall of (interesting) text.

good but depressing read. want moar!