Tag Archives: health insurance

Health Policy Costs Us All

For more years than I can count, opponents of “socialized medicine” (i.e., single-payer, universal health insurance) justified that opposition by assuring us that we were “number One!” American healthcare was the best in the world, thanks to the innovation that was made possible by our refusal to extend that healthcare to everyone who needed it.

As the world got smaller, and more Americans traveled abroad, we began to realize that we really weren’t number one–that in fact, those global indices that ranked us somewhere around 37th or 39th were onto something.

More recently still, medical tourism became a thing (at least, pre-pandemic, when we weren’t shut out of healthier countries.) Americans are traveling to have procedures–and babies!–in places where the care is just as good or better, but much cheaper. 

There’s a reason so many reasonably well-educated, reasonably well-meaning middle-class Americans were so slow to recognize the gargantuan flaws in America’s patchwork approach to medical care–and for that matter, all social services. So long as we remain lucky and privileged, accessing health insurance through our employers, not getting a rare or terribly expensive disease, not having to navigate a system designed to say “not you,”  there’s simply no way we could imagine the experience of those who aren’t so lucky or privileged.

For years, I fell into that “lucky and privileged” category. But many years ago, when a diagnosis meant that my oldest son was unable to work, I encountered the Byzantine world of Social Security disability. At the time, it took two lawyers (me and my youngest son) and a friend who headed a social services agency to navigate the process.

When I asked my oldest’s then-doctor what happened to people without family lawyers and savvy friends, he said simply, “They die.” 

Just over a week ago, we got another lesson. My oldest grandson and his wife had a very premature baby. Born at just over 26 weeks, she is in the NICU, life-lined and hooked up to a tangle of machines and devices. My grandson and his wife take turns being with this much-desired little girl (and when I say “little,” she was one pound five ounces at birth, and about the size of my grandson’s hand.) The stress they are experiencing is etched on their faces.

In addition to the helplessness we feel watching this unfold, the whole family has worried about costs that their insurance won’t cover. If there is anything they don’t need,  especially right now, it’s thousands of dollars in out-of-pocket expenses. My granddaughter-in-law’s sister was so worried she set up a Go Fund Me page, something that wouldn’t be needed–or even comprehensible–in “socialized medicine” countries. (I have a son who lives in the Netherlands and an adult granddaughter who lives in England, and both sing the praises of their healthcare systems.)

We were relieved–and surprised– to learn that there are government programs that  provide at least some measure of secondary insurance in these situations. It’s just that no one in our (reasonably well-educated) family knew they existed until now. And I’d be willing to wager that, unless you are a social services or health insurance worker, those of you reading this haven’t heard of them either.

There is an important public policy lesson here–not to mention a lesson about equity.

This country spends far more than any other country in the world on medical care–twice as much per capita as the next most expensive country. (But hey–“We’re number 37!”)  That includes significant amounts on a patchwork of low-profile programs that help eligible people who manage to find out about them, and still more on the bureaucracy that serves as a “gateway” to those programs.

Think how much we could save if we replaced that haphazard patchwork of complicated and under-inclusive programs with some version of Medicare-for-All. Of course, a simple, single-payer health insurance system with a common and comprehensible “entry point” would serve all citizens, not just empowered ones–maybe that’s why we don’t have one.

There is some evidence that American voters are beginning to catch on.  In a recent column for the Washington Post, E.J. Dionne wrote:

No matter how hard they tried, Republican politicians and their allies could not stop Missouri’s voters from expanding access to Medicaid under the Affordable Care Act.
They tried to rig the timing of the referendum by forcing the vote during a relatively low-turnout primary on Tuesday rather than in November. That failed. They played on racial prejudice and nativism by falsely claiming a yes vote would mean “illegal immigrants flooding Missouri hospitals . . . while we pay for it!” That failed, too.
And so did Missouri this week become the sixth state since 2017 — five of them staunchly Republican — where voters took the decision on the expansion of health coverage out of the hands of recalcitrant conservative politicians.

You shouldn’t have to have a social work degree (or a friend with one) in order to access government insurance against calamity.

And Republicans should stop kidding themselves–calamities don’t just happen to “those people.”







While the media and the country are being distracted by the daily crazy/sleazy coming from Washington, the Trump Administration is working feverishly behind the scenes to dismantle the rules: rules that protect us from dirty air and water, from discrimination in housing and education, and rules that guarantee us access to health care, among others.

The unremitting attack on the Affordable Care Act has been particularly effective. The GOP may not have been able to repeal it outright, but regulatory sabotage has been the next best tactic. Thanks to the administration’s actions–neutering and threatening to eliminate provisions of the ACA that were included in order to keep premiums affordable, health insurance rates continue to rise.

According to Larry Levitt at the nonpartisan, respected Kaiser Foundation,

New analysis: Insurers did very well in Q1 of 2018 in the individual market under the ACA. If not for looming repeal of the mandate penalty and expansion of loosely-regulated plans, we’d be looking at modest premium increases and even decreases for 2019.https://www.kff.org/private-insurance/issue-brief/individual-insurance-market-performance-in-early-2018/ 

Evidently, however, the administration has decided that killing affordability by raising costs was too incremental; a recent article from The Washington Post reported on a much more direct attack.

The Trump administration took another major swipe at the Affordable Care Act, halting billions of dollars in annual payments required under the law to even out the cost to insurers whose customers need expensive medical services.

In a rare Saturday afternoon announcement, the Centers for Medicare and Medicaid Services said it will stop collecting and paying out money under the ACA’s “risk adjustment” program, drawing swift protest from the health insurance industry.

Risk adjustment is one of three methods built into the 2010 health-care law to help insulate insurance companies from the ACA requirement that they accept all customers for the first time — healthy and sick — without charging more to those who need substantial care.

As the article goes on to explain, two of the three methods were temporary;  risk adjustment, however, was to be permanent. Federal health officials are supposed to annually calculate which insurers had relatively low-cost consumers, and which had more expensive customers. Those with the lower-cost customers would make an adjustment payment to those whose customers were more costly.

This idea of pooling risk has had significant practical effects: encouraging insurers to participate in the insurance marketplaces the ACA created for Americans who cannot get affordable health benefits through a job.

In its announcement, CMS said that it is not going to make $10.4 billion in payments that are due to insurers in the fall for expenses incurred by insurers last year.

The announcement that payments due under the law would simply not be made is just the most recent measure taken by the Trump administration to demolish a law the GOP was unable to repeal legislatively. (It’s a tactic Trump is undoubtedly comfortable with–throughout his “successful” development career, he routinely stiffed architects, engineers and contractors. Wheelers and dealers who are willing to ignore the terms of contracts to which they are party are unlikely to have qualms about ignoring the obligations imposed by laws to which they are subject. But I digress.)

The administration has taken a number of steps to dismantle the ACA through executive powers.

Last year, health officials halved the length of the annual sign-up period for Americans to buy ACA health plans and also slashed by 90 percent the federal funds for advertising and other outreach efforts to urge people to enroll. Last October, the president ended another important subsidy to insurers: cost-sharing reduction payments, which cushioned them from the law’s requirement to provide discounts on deductibles and other out-of-pocket costs to low-income customers.

This year, the Department of Labor and HHS have worked to make it easier for people and small companies to buy two types of insurance policies that sidestep benefits required under the ACA and some of the law’s consumer protections.

There have been a couple of lawsuits in the lower courts over past calculations of these payments, with inconsistent results, and the administration blamed the withholding of funds on one of those decisions–a transparently trumped-up excuse. (Pun intended.)

“Risk adjustment is a mandatory program under federal law,” said Scott Serota, president of the Blue Cross Blue Shield Association. “Without a quick resolution . . . this action will significantly increase 2019 premiums for millions of individuals and small business owners. . . . It will undermine Americans’ access to affordable coverage, particularly for those who need medical care the most.”

Matt Eyles, president of America’s Health Insurance Plans, noted in a statement that the timing of this latest move could be particularly disruptive, because this is the season during which insurers around the country decide whether to take part in ACA marketplaces for 2019 and, if so, what rates to charge. “This decision . . . will create more market uncertainty and increase premiums for many health plans,” Eyles said.

Of course it will. That’s the whole intent.

And if thousands of people are bankrupted or die as a result? Too bad. They weren’t Republican donors anyway.

And Now, The Rest of the Story…

This will be my final post about my personal odyssey with the fine folks at Anthem. It will be brief, just to update those of you who’ve been so kind with your suggestions and good wishes.

You will be happy to know that Anthem has made medical school unnecessary.

Yep–when they finally returned the multiple calls from the hospital doctors, and those doctors had once again gone through the charts, the X rays, the reports from in-hospital PT, etc., they were told that according to Anthem’s algorithm, I am not a candidate for rehab.

Their algorithm, you see, knows more about my condition and needs than the medical personnel who actually examined and treated me.

As one doctor said, “why did I waste all that time in medical school?”

I’m going home. My younger grandchildren will come over to help my husband with my care, at least for a couple of days, and we’ll figure it all out. (As those of you who know me know, I’m a tough old bird.) But everyone in this situation–as you  can see from the multitude of comments here on the blog and on Facebook–isn’t as fortunate as I am, doesn’t have a support network that can step in. And according to the doctors and caseworker, I am far, far from the only person facing this bureaucratic malpractice. And I will follow up on several of your recommendations for filing complaints, etc., in hopes that I can keep at least some others from going through a similar fiasco.

The United States is the only developed country in the world that has chosen to socialize its medical care through the insurance industry.

I asked one of the doctors if they have these same problems with Medicare. They don’t.

For now, this blog will return to its originally-scheduled programming.



Inexplicable, Costly and Wrong; An “Extra” Blog

Okay, I defy anyone to explain this to me.

As regular readers know, I’m in the hospital recuperating from a nasty fall. I broke my pelvis and my clavicle. I’ve been here 8 days, although the doctors wanted to send me to acute rehab three days ago. (Acute rehab is apparently more intensive, appropriate for people who have been active and can be expected to respond to longer sessions of physical therapy–and thus leave for home more quickly.)

This morning, I was finally supposed to be transferred. But then, Anthem, my “insurance” company (note the quotes) rejected the doctors’ advice and denied the move. According to the caseworker, since the first of the year, insurers have been denying approximately 50% of requested moves to acute rehab. Without seeing the patients, without consulting with their doctors. The hospital can and does appeal, and about half of those “peer to peer” appeals are granted–we’ll see what happens with mine–but even the appeal process evidently becomes a game; calls are routinely returned after hours, for example, when the insurance company knows the physician won’t be available, prolonging the process.

But here’s what is insane: keeping me in the hospital costs more than sending me to rehab.

Why would a company that should want to keep costs down opt for a placement that (1) is medically inappropriate; and (2) costs more? Why did the approval process suddenly become more arduous at the beginning of the year? What is the larger game being played in which I find myself a pawn? And what therapy will Anthem pay for? Anything? Or is my 83-year-old husband supposed to drag me up the stairs at our home and help me in and out of bed when nature calls?

Tell me again how horrible single-payer systems are

Growing Old is Not for Sissies….

Each morning, when we get up, my husband and I look at each other and remark that growing old is not for sissies. An incident Tuesday proved it. We’d been at a son’s house for dinner, and when we came out onto his back deck, it was dark and drizzling. I missed a step, and went down hard on a brick walk, fracturing my pelvis and clavicle.

I’m posting this from the hospital, and it looks as if I’ll need a couple of weeks in a rehab facility before going home. It will heal and I’ll be fine–but it will take some time, and it requires juggling a lot of commitments and inconveniencing a lot of people. (If I miss a day or two of posting–which I hope won’t happen, but may–you’ll know why.)

When something like this happens, it not only interrupts the habits and daily flow of life, it also prompts some unwelcome thinking about growing older and the fragility of life. On the other hand, it’s a reminder of what’s really important–family, friends, and meaningful work.

But you can never entirely take the nerdiness out of someone who teaches public policy, so this was also an occasion to be grateful for good health insurance, and to wonder–once again–why efforts to extend that same peace of mind to others evokes so much resistance. A fall like mine could bankrupt someone without coverage–a missed step on a rainy night could mean loss of a home, savings, the ability to send a child to college.

Why would anyone fight to continue a system like that?

On Facebook a couple of days ago, someone posted a picture of a hat shaped like the one Donald Trump has been wearing–the one he emblazoned with “Make America Great Again.” This one, however, had a different  and far better sentiment.

Make America Kind Again.