Wednesday, January 31, 2007

Health Insurance Just Needs To Be Affordable

I did something today that I absolutely LOATHE--paid a visit to my family doctor.

No, it's not that I dislike wanting to feel better when I am sick. Nor am I so ignorant that I would not want to get treated by professionals who have dedicated their lives to making people better. But something has seemed to change almost overnight in recent years within the health industry that is quite disturbing to me.

It's this business of health insurance. More specifically, the affordability of getting QUALITY health insurance. What the heck has happened to the cost of healthcare nowadays that everything has to cost so much money for the average person to get basic coverage? It's enough to make your blood pressure rise (but I can't afford to see the doc about it!)

Sure, rising healthcare costs undoubtedly have a lot to do with the rapid increase in obesity-related diseases like diabetes, heart disease, hypertension, and cancer, just to name a few. In fact, Medicare costs have tripled because of doubling obesity rates, so it's a real problem that is rearing its ugly head. And diabetes costs $132 billion annually to treat. I have chronicled why these issues exist and how to correct them through livin' la vida low-carb many times since I started this blog.

But getting back to the subject of health insurance for the average American, now we have literally tens of millions of families who don't have ANY health insurance at all. Yikes!!! This has become personal for me now because you can count my family among the ranks of the uninsured.

When I was employed by a fairly large company up until October 2006, I had pretty good health insurance through one of the most well-known companies providing health insurance today. The premiums were reasonable for the insurance which only required a small co-pay for general doctor visits and prescriptions while covering my wife's gall bladder surgery and tests at virtually 100%. Like I said, it was GOOD coverage.

However, losing that job meant losing that insurance unless I wanted to pay through the nose for the COBRA coverage that was extended to me. I decided to pass up the COBRA because the cost was much too unreasonable financially with the uncertainty about what my next job would be.

While we are on this subject, why does health insurance have to be tied to your place of employment anyway, hmmm? That seems like a screwy way to provide adequate coverage for the millions of Americans who work for small businesses that can't afford good group coverage plans. Believe me, I've had a few of them and you've got to be rich to afford the medical care! What's the point in having insurance?!

At the same time, I've also worked for big companies that have more purchasing power when providing health benefits to their employees. And that's a bonus for the people who are privileged to work for these companies. Think about it, though, that doesn't seem right now, does it? Why should your job determine the quality of your health insurance?

Can't we somehow pool the resources of the self-employed, small businesses, and individuals without health insurance and come up with the largest group policy plan in the country we could call the U.S. Health Insurance Plan that would provide that same kind of GOOD health coverage (like people who work for the government get!) at an affordable cost?

Plus, without delving into the politics of this issue (I REALLY don't!), why does this issue have to be so politically charged when people are seriously hurting for help? This isn't a Democrat or Republican political football that can be passed back and forth between elections while NOTHING is done about it. We need REAL solutions and not more empty pie-in-the-sky promises imploring class warfare.

And, lest I am misunderstood, I am NOT advocating universal healthcare coverage like they have in Canada with people being put on extremely long waiting lists for operations, transplants and the like. I don't want FREE healthcare, just insurance that is affordable and effective. Is that too much to ask?

Getting back to today's office visit, it was not for me, but my wife Christine. She bumped her knee on something a couple of months ago and just let me know last week that it still hurts (um, honey, were you gonna let me know about this anytime soon?!). She was afraid to bring it up because we are without health coverage right now. That's sad, isn't it?

Actually, we TRIED to buy health insurance from a company that will remain unnamed here and we actually got approved for the reasonably-priced policy rather quickly at the end of December. But when we went to use it for another medical issue Christine had a few weeks ago, the terms of the agreement as explained to me by the insurance salesman were not the same in reality.

We were told that we would have $1,000 that we could spend on doctor visits which seemed like PLENTY of money for an entire year. But after Christine's first visit which cost about $200, the insurance company said we could only use $50 until the end of the first quarter. Say what? Yeah, it seems the $1,000 is cut up into four $250 increments for each quarter. Who PLANS to get sick spread out over the year?!

Needless to say, after several back and forth conversations with them about this and other discrepancies about the plan we thought we had bought, both the insurance company and I mutually agreed it was best to drop the coverage and find another place for health coverage.

So that's where I'm at right now. I WANT health insurance, but finding a good plan for the right price is the tricky part. Where do you go for such coverage in this volatile environment? Since when did this issue get to be so complex that people would rather risk NOT getting sick than to pay through the nose on medical costs?

Here are my three bare minimum basic requirements for a GOOD healthcare plan:

1. I must be able to use it with my family doctor whenever I get sick or go for a routine checkup and have full coverage with a copay of no more than $25.

2. Major coverage (around 90%) for any big medical emergencies that may need addressing, such as heart attack, stroke, cancer, etc.

3. Prescription drug plan that has a $10 copay for generics and $25 copay for prescriptions.

Speaking of prescriptions, while I was in the waiting room for an hour listening to my iPod as Christine was getting her knee x-rayed and checked out by her doctor, I was stunned to see how many pharmaceutical reps came through this office. You can see them coming a mile away: nicely dressed, usually good-looking, carrying a gigantic tote bag (of drug samples) with their latest miracle pill they are pushing, and wearing a name tag of who they represent.

Guess how many I saw come in and out while I was there? 2? 4? How about EIGHT of them in all! They've got the system down pat, too--sign in at the front desk at their special sign-in sheet and just walk back in front of the patients who have been waiting for umpteen minutes in the lobby area while their doctor gets schooled on the next can't-live-without-it drug. UGH UGH UGH! Isn't that so tacky?!

Worst of all to me is the fact that they come bearing gifts like a lobbyist on Capitol Hill trying to woo a Congressman to vote for certain key pieces of special interest legislation. The same goes for these pill peddlers. I saw one of them hand about ten items to the front desk receptionist out of her big bag that undoubtedly had the logo of her company and/or name of her drug plastered all over it.

I know people need to make a living somehow, but that's one occupation just about as crooked as a used car salesman or a trial lawyer is. They are helping their companies rake in literally hundreds of BILLIONS of dollars annually by convincing doctors to prescribe drugs to their unsuspecting patients that are questionable at best for treating disease while natural remedies like livin' la vida low-carb and the overwhelmingly positive research coming out about it is simply ignored. Why? It's FREE and money can't be made pushing a healthy lifestyle change!

Okay, enough of my soapbox, what do you think? Have I just become too cynical about the healthcare industry these days that I've become jaded to reality? Or, is it somehow better than I'm making it out to be? Or quite possibly could it be even worse? I would LOVE to hear from doctors, pharmaceutical reps, the uninsured or underinsured, and anyone else who plays a role in this debate.

There are no easy answers, but there must be a way to make this all work for the benefit of every American who wants and desires the opportunity to insure the peace of mind that comes from knowing you have a plan in place in the event a health calamity should hit. Does such a plan already exist and I just don't know about it?

If you know of or represent a health insurance company that meets my basic requirements, then I am VERY interested in learning more about that plan. Please send any information to me at I look forward to reading your comments in response to this issue that will not be going away anytime soon.

Oh, by the way, Christine's knee is fine. She has a deep contusion that the doctor said may take as much as nine months to heal. There was nothing he could do to alleviate the pain and fix her knee. That little visit to tell Christine there was nothing he could do for her cost a cool $150! Man, I'm in the wrong profession!

1-31-07 UPDATE: I received the following response from one of my regular readers who just happens to work in the medical industry and has firsthand knowledge (and of course commentary) about health insurance.

Ah, Jimmy! My husband is a physician and I file the healthcare insurance for our patients. I'm sorry to say it, but you're asking for the impossible. Everything is a tradeoff.

Do you want to be able to sue your doctor for malpractice? Then be prepared to have him order umpteen tests you really don't need, just so he'll be able to cover his rear end in court when the time comes.

Do you want new drugs developed for your diseases? Then expect drug companies to act like a business and not like a charity. What's the latest chemotherapy drug developed by a charity?

Do you want to pay low copays? Then you'll see a limitation somewhere else--the number of visits, the doctors you're permitted to see, the size of the premium paid by you plus your employer.

Do you want nationalized health insurance? (I know you don't but lots of people do.)Then recognize that the cheapest outcome of all is--death. Heroic measures cost a bundle. If the nationalized healthcare system makes you wait for your cardiac cath or your liver transplant or whatever, there's a good chance that you will simply die and avoid all those unnecessary expenses. And if there's only one national insurer, the patients can't take their business elsewhere, can they?

I'm not too fond of the current system either. I scream at the stupidity of insurance companies all the time.

My husband and I have a policy with a $20,000.00 deductible(!), so we get to pay for all our prescription drugs and office visits out of pocket (no professional courtesy anymore). Believe me, we shop around!

We finally found a clinic that takes cash only and has contracted with specialty doctors in the community for reasonable rates, also in cash. They've saved so much money by not dealing with insurance that they can pass the savings on to their patients. What we pay for an office visit there is less than the copay many of our patients have to pay on their insurance.

Okay, rant over. Hope this information helps!

Plenty to chew on there. THANKS for sharing your unique perspective. Anyone else?

2-2-07 UPDATE: Here's another perspective from someone who sells insurance.

Hi Jimmy,

I enjoyed your article and I share your frustration. I'm a self-employed insurance agent and guess what, I have to buy this stuff, too. I don't like the price of health insurance either.

For the last twenty years or so politicians and the media have framed this issue as a "health insurance" problem, as if insurance companies manufacture money. The problem is a "healthCARE" problem, and one glaring fact that everyone in politics and the media leave out is that we have a LARGE population of baby-boomers who are getting older and starting to file more claims as their parts begin breaking down.

I'm one of those baby-boomers. I'm 55. Thirty years ago when my peers and I were in our 20's we paid premiums but didn't file many claims. As a group, we actually helped hold the cost of medical insurance down for everyone else for a couple of generations. Now we're filing claims and it's our claims that are raising the average cost of premiums for everyone else. No one gave us credit for keeping costs down, so I guess it's good that we're not getting the blame for forcing them up now, but that's the reality.

Your comments about low co-pays interest me. When a drug or a medical service costs more to provide than the co-pay you paid, who pays the difference? The answer: someone else. When other people pay co-pays that are less than the cost of the drug or the medical service, who pays the difference? Answer: YOU DO.

That's all that any kind of insurance arrangement is, a cost sharing plan. When bad things happen to you, other people help pay for it. When bad things happen to OTHER people, YOU help pay for it.

I understand your desire for a low co-pay, but it's not realistic and never has been. Co-pays were a method that the insurance companies used to force doctors to join preferred provider organizations ( PPO's ) back in the early 90's. The insurance companies basically bribed patients into demanding that doctors join PPO's by discounting their regular fees so that the insurance companies could hold their premiums down.

Insurance companies aren't stupid. They know that if prices get too high the government will nationalize their industry. Their co-pay strategy worked but now consumers have become accustomed to them and seem to think the difference is paid from some magical pot of money somewhere. It isn't. It's paid by other policyholders like you.

The future of healthcare, if it isn't taken over by the government (which might happen) lies in consumers taking more responsibility for their healthcare expenses. Insurance plans with high deductibles, coupled with Health Savings Accounts are the future, in my opinion. I suggest you take a look at some of those.

Having a family and going without ANY health insurance is like risking EVERYTHING YOU OWN at Vegas without actually having any fun.

Our governor down here in Texas, a Republican named Rick Perry, had an interesting quote the other day. He said healthcare is the only industry where the consumer doesn't know what services actually cost, and it has no incentive to care because someone else is paying the bill. Sums it up pretty well, in my opinion.

Finally, I have a funny story to share with you, too. A few years ago I was visiting with one of the small businesses whose health insurance I used to handle. It was a doctor's office and I was meeting with the doctor's wife to discuss their options for dealing with the rate increase their health insurance carrier had just issued for them and their ten employees. Doctors have to buy health insurance, too.

The doctor's wife was REALLY complaining about insurance companies and their prices when there was a knock at the door. It was her husband, the doctor, and he had an attractive young lady with him. "This is Laura. She's from Merck Pharmaceuticals and she wants to know what night next week she can take us to dinner at The Mansion on Turtle Creek". ( Look this place up. It's probably the most expensive restaurant in Dallas. Movie stars stay there when they come to Dallas.)

The doctor and his wife decided that the following Thursday would be best, the doctor closed the door, and the doctor's wife went right back to complaining about the high cost of health insurance premiums.

I get cracked up every time I think about that woman. Good luck in your search!

Oh, that story at the end was TOO FUNNY! Here was my response back:

THANKS for your insights. I agree with most of what you wrote and have looked into medical savings accounts as my best option right now. I've stayed healthy since losing my weight, but my wife Christine has several medical needs for her eyes and back. She's the one I'm concerned about making sure she is covered.

It's not an easy problem to solve, but it must start with the consumer making good choices for themselves and stop relying on the free ride they expect from their health insurance. People who keep themselves healthy and away from the doctor should not be penalized for being well. It's almost like you should get sick to make health insurance worth the cost. And that's sad.

THANK YOU again for your comments! I REALLY appreciate them. Take care!

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Blogger Calianna said...

"Here are my three bare minimum basic requirements for a GOOD healthcare plan:

1. I must be able to use it with my family doctor whenever I get sick or go for a routine checkup and have full coverage with a copay of no more than $25.

2. Major coverage (around 90%) for any big medical emergencies that may need addressing, such as heart attack, stroke, cancer, etc.

3. Prescription drug plan that has a $10 copay for generics and $25 copay for prescriptions.

That sounds like an absolute fantasy health insurance to me!

Well, you *might* be able to get coverage that good.... if you're willing to pay about $2,000/month for it... per person. Assuming you can find coverage that good at all.

Aside from someone I know who works in a government office (local police - and she actually has 100% coverage on everything, amazingly enough), no one I know has that kind of health insurance any more. Ours has become more costly, covering less and less each year, for the last several years.

Forget being able to go to your usual family doctor, you're required to go to one that's contracted with your insurance company, unless you want to pay a lot more for the privelege of choosing your own doctor. You might be able to find one group in your area that's in your plan.

I have one friend whose health insurance was so bad that there was only one doctor in one group in a city 50 miles from where she lived that was affiliated with her husband's work insurance. If she got sick on a day that particular doctor was out of the office and ended up seeing another doctor in the group (or if she was switched to another doctor after making her appointment in advance, because her regular doctor had an emergency, or felt the need for a vacation), she'd be charged full price. Her insurance wouldn't pay a penny.

Around 80% coverage for hospitalization or emergencies seems to be pretty good these days - many plans only cover 70%. Don't forget to get pre-approval from the insurance company before being admitted though, or you'll end up footing the whole bill yourself again.

The prescription plan you want doesn't sound too far off the mark for what most prescription insurance seems to offer these days, except that the copay for the non-generics will have at least 2 price tiers - the cheaper drugs that they want you to use first, and the more expensive drugs that they'd prefer not to have to pay for at all. Which is why they make you pay at least $60 or $80 of the cost of higher tier drugs, in order to discourage you from using more expensive drugs. Allergic to all of the cheaper drugs? Tried all the cheaper drugs with no results? Too bad, you'll still pay the higher cost for the ones in the next tier.

Oh, and don't forget deductibles, in addition to the copays and finding an "in plan" doctor. We had a choice this year of having a huge deductible (several thousand dollars), or going with a somewhat smaller deductible for a larger monthly payment. If you added up the monthly costs, plus the deductibles, plus the copays, up to the maximum out of pocket worst case scenario costs for the two choices, they ended up costing almost exactly the same for the year (except that the lower deductible plan never reached a maximum amount on the prescription portion, so it had the potential of costing a lot more).

So how did they convince nearly everyone to go with the higher monthly payment/lower deductible plan? By saying that you'd have to pay the full higher deductible amount before anything at all would be covered. Never mind that you were going to be paying nearly that much more in monthly costs with the lower deductible plan, whether you needed any health care or not during the year.

Insurance is quite a racket, the balance is always tipped to make sure they make a good profit on whatever plan you use. The insurance companies are in it to make money, there's absolutely no mercy.

2/02/2007 9:20 AM  

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