Luckily, my husband and I both have jobs, and, unlike over a quarter of our fellow Americans, we have health insurance.  Or so we thought.  Over the last 3 or 4 years, we have noticed a trend that has bled our savings and made us ask the question—how insured are we?

            I’ll try to answer the question after I move my conclusion up to this paragraph.  As a card-carrying progressive, I support and advocate for a safety net of single-party payer insurance for the United States.  What I mean by those catchwords, is a national health program that is independent of employment, that is managed by an altruistic, uncorrupted agency whose mission is service rather than profit.  The government, in ideal circumstances, would be the caring coordinator of this program, which would be funded by progressive—not regressive—taxation.  I also would not object to additional insurance being available for purchase above and beyond this safety net for “luxury care”—as long as the “luxury care” involves cosmetics and not medical quality of care.

            Yes, I know.  Health care costs are rising exponentially, approaching 20% of our GNP.  How can we afford to pay for the medical needs of our large and growing population?  Again, my conclusion is: high percentage taxation of the top 1% wealthy, and, immediate cessation of the waste of trillions of dollars for murder and graft overseas.  And, I know Santa will have this gift wrapped up for us by December, ho, ho, ho.

            Okay, until Santa, the Easter bunny, or Barack make this dream happen, we are grateful to have “insurance”.  Or were.  This year, our family has faced several medical situations that have required emergency room visits and surgeries.  As part of a preferred provider organization, we pay over $1300.00 a month in premiums, supported by our employer’s two third’s co-pay.  So, our family is putting over $5000 dollars a month into the insurance company’s till.  Theoretically, this buys us the ability to see a large list of doctors in multiple specialties in the insurance company’s plan, our bills paid at an 80% rate, as well as to have our hospital expenses fully paid beyond a $3000 cap.  We are fortunate to be able to put aside up to $10,000 a year to cover the medical “incidentals” we projected.  How many working families have that luxury, when mortgages, food, and gas have eaten into salaries that have not seen cost-of-living increases for years?

            Unfortunately, our bills have been far higher than our worst-case projections.  Why?  Well—one physician colleague in private practice explained it directly:  “Doctors aren’t signing up for PPO’s any more.”  Our internist, pediatrician, eye doctor, and gynecologist have, within the past two years, decided to no longer accept any insurance, opting instead to follow other trades in expecting a large fee for service.  Unfortunately, while we can live with a dripping faucet and save the several hundred dollars in plumbing costs until our budget is replenished, our body’s “drips” are more urgent.  How many visitors to state or county funded public hospitals have of necessity waited until they are seriously ill because they are unable to afford the thousands, not hundreds, of dollars to fix their medical conditions at an earlier stage?

            Why not submit the doctors’ bills to the insurance company ourselves?  Well, this hypothetical example outlines the challenge.  In a PPO, the signing doctors agree to charge $200 for the 15 minutes it takes to fix “hangnailitis”.  ($800 an hour!  That’s outrageous!)  The doctor bills the insurance company, the insurance company then pays 80% ($160), and the patient gets the service for $40.  (Which is what it should cost in the first place!)  If the MD is not in the PPO, however, the scenario goes like this:  The doctor isn’t forced to “cap” the fee at $200 for hangnailitis and charges $500.  The patient has to pay up front, then files with the insurance company for reimbursement.  The insurance company, however, only calculates the reimbursement from the $200 they pay “their” doctors.  So, the insurance company reimburses $160, and the patient is out $340.  Ouch!

            Okay, so you bite the bullet and choose other doctors in the PPO plan.  But what happens if you have to go to the ER?  In the past, the great majority of ER’s were bundled in PPO plans.  Now, many are not.  And, even those that are in a PPO plan have negotiated different rates with the plans.  For example, ER #1 charges $10,000 for a “chest pain” visit—but lowers the rate to $2000 for those in the plan.  The plan then pays 80-90% and the patient sees a bill of no more than a couple of hundred dollars.   ER #2 however, has negotiated to lower their fee to $4000—the plan still pays a percentage, but the patient ends up with a bill of thousands.  As the ambulance is racing to the ER’s, cost comparisons are not usually available.  In fact, they need significant detective work to discover even online. 

            And, now, where the ER costs in the past were fully covered by the ER visit charge, ER’s have started to contract with ER MD’s separately.  The end result of that action, is that a patient can be taken to an ER that is under one’s insurance plan, but have thousands of dollars in bills from the doctors that care for him who are not in the plan.  The patient, just like we were, is effectively uninsured.

            As a salaried physician myself, I am keenly aware that those even with some insurance are better off than the millions without.  But I and my colleagues who work in a clinic setting for relatively low salaries, have difficulty understanding why our colleagues in private practice are unable to make ends meet despite charging hundreds of dollars an hour and seeing large numbers of patients on a treadmill that wearies physicians and leaves patients unsatisfied.  Ah, yes, one complaint does ring true—insurance company reimbursements to doctors are often delayed or denied.

            All right.  It’s broken, folks.  Very, very broken.  Let’s fix it.  First, let’s talk about medical schools:  stop graduating doctors with hundreds of thousands of dollars in debt.  They’ll go into rich areas and try to make payback money.  Subsidize the cost of medical school for all who cannot pay up front and then have the subsidized MD’s do a 4 year payback as salaried physicians in underserved areas.  This change might encourage students whose motivation is service rather than glamour or profit to enter the profession.

            Secondarily, make a societal commitment to the “basics”.  If you want to make a profit selling LCD TV’s or luxury cars, go to it.  But healthcare should be a right, and not a profit industry.  Get rid of the leeching middlemen:  insurance companies, obscenely paid health care executives, etc,… and expand Medicare to our entire population.  Provide doctors with a reimbursement that allows them to earn up to $150,000 a year in a reasonable practice of 40-60 hours a week, and take any “profits” the system generates and re-circulate them back into the healthcare system, not to executives or stockholders.  By removing unneeded layers of business management, the funding needed to support a national health program will be reduced.  Then, the funding needed can be drawn from taxes that are highest for the richest Americans.  For those in lower income brackets, a health tax vs. the funds paid out of pocket for insurance and healthcare today could be a wash—or a refund.

            The insurance companies and the for-profit healthcare providers and managers have made a mess of our health care system.  A Democratic administration must not fall into the trap of continuing to subsidize these voracious profiteers by “requiring health insurance”, or encouraging for-profit HMO’s.  A recognition that healthcare should not be a business should help drive the profit pirates to a less critical field, and leave the provision of services to caring doctors and relieved patients.

            Flat screen TV’s anyone?