I had a blood clot. The good news was it was superficial - meaning in a surface vein, not one that led to the heart or lungs. Medline Plus says this condition is "usually a short-term condition that does not cause complications. Symptoms generally go away in 1 to 2 weeks...." So, basically, it's not a blood clot that will kill you but, as I learned a year later, it will keep you from getting health insurance. My treatment was similar to a muscle strain. Rest, elevate, ice. My doctor had me take a baby aspirin a day and told me not take birth control pills just to be on the safe side, but said I didn't need to worry about it. That lots of people get these and never even know it. Also that everyone should get up and walk around to help prevent clots rather than staying in one position for long periods.
I started my law practice as planned. Just over a year later, I applied to Blue Cross for an individual policy, hoping that, given that they had my records and knew my health, they would just extend my current coverage. That's not how it works. I filled out a long form. It covered the last 5 years in depth, but asked about my medical history for my entire life. It did not ask about my general health habits, other than not smoking. There was nowhere to list that I walked 10 miles a week, did yoga 3 times a week, and practiced meditation. I'm sure I went into more detail than many people would about my medical history, including my eye surgery at the age of 4. If I'd omitted anything, even by mistake, I knew I could find myself without coverage down the road right when I needed it. For instance, let's say I forgot about the eye surgery, then three years later I was hit by a car and needed surgery on my leg. If the insurer found out I'd omitted the eye surgery and could show that was material -- meaning the insurer would have denied coverage if it had known -- it might then refund all the premiums I'd paid and leave me without health insurance. I could then be facing over $100,000 in hospital bills with no health insurance. (Hospital bills can easily run above $100,000 when a pedestrian is hit by a car.)
How much I included on the form, or in the follow up telephone interview, turned out not to matter. The insurer wrote a letter saying it was rejecting me because of the blood clot without looking at anything else. I'd just met a health insurance broker at a networking event who'd warned me that 40% of people get turned down when they apply for individual coverage. I called him, and he helped me through the process for another major carrier. That application was just as involved, plus I had to disclose that I'd been turned down for health insurance. I was turned down again.
Both carriers sent me information on the Illinois Comprehensive Health Insurance Program. ICHIP had two programs I qualified for, both for people who had no group coverage available to them. One was for people who'd kept their COBRA coverage the entire 18 months and wanted to continue insurance. That had no waiting period and picked up as soon as my COBRA ended so long as I filled out all the correct forms. The second option covered those who'd been turned down for individual coverage. That program often had a waiting list, then excluded pre-existing conditions for a set time, something like six months. I opted for the first plan. The people administering it were very helpful and always available by phone when I called. And I got the Blue Cross PPO.
My plan has a $5,000 deductible and costs around $300/month (based on being a 47 year old female non-smoker). Nothing is covered under the $5,000, so I was a bit shocked when I discovered my allergy nasal spray was over $100 per month. I'm very fond of breathing, though, and the less expensive medications I tried didn't work, so I paid it. I could and probably should have gotten a lower deductible, but I'd been very healthy, so I figured it was worth the risk. I hit my deductible one year, when I had to have surgery (see Goodbye Ovaries below).
One thing worried me -- I was required to pay my premium by certified, not personal, check. And all over the premium notice it said if I missed the premium, my insurance would be gone and I could never reinstate it. Before my surgery, I thought, what if I have a tough recovery and can't get to the bank to get a certified check? So I prepared a financial power of attorney to be sure someone could do it for me. I also didn't know what I'd do if needed to move out of state, as ICHIP is only for Illinois residents. Fortunately, I love Chicago.
Other than that, I've been happy. I got to keep my doctors. I've learned a lot about healthcare pricing. That's led me to think that a co-pay based on a percentage of the actual charge might be a good thing, as otherwise the co-pays are completely disconnected from the amount of the bill. On the other hand, I also learned the actual bill has little to do with reality, so long as you are insured. My surgical bill and emergency room bills were something like 3 times the PPO rates. So even before I hit the deductible, the insurance was valuable, as I still paid only the PPO rates. If I'd been uninsured, I would have been liable for the whole amount.
Now my ICHIP program is going away because the Health Insurance Exchange is supposed to make it unnecessary. According to the state, this should mean my premium will be cheaper because the ICHIP premium is always set at 150% of what the rate would otherwise be. I'm relieved that, unless Congress makes changes, health insurers can't deny me coverage. I'm also happy I'll have the option to cover employees, if I hire any again, through the exchange. (I've had a few different part-time employees over my five years in practice.) And, presumably, if someday I want to leave Illinois, I'll still be able to get coverage.
I'm concerned, though, that Congress will succeed in getting rid of the insurance exchanges, and I will then be stuck with no ICHIP and no coverage. I'm also concerned about whether I'll be able to keep the Blue Cross PPO. I heard that premiums will vary with network size. So the cheapest plans will have smaller networks; the Cadillac plans will have wide networks.
On 10/1, I will go on the exchange and see what I can see. Even before I read articles raising potential technology issues, it seemed unlikely to me it would all be working on Day 1. I figured that for the same reason I try not to buy a new Microsoft version of anything. The ones I've bought have always had bugs. (It was a nightmare when I bought a computer with Windows Vista when it first came out. I used to walk around the office saying "I hate Bill Gates" over and over. But I digress.) I don't expect the government will do better than Bill Gates. On the other hand, I was pleasantly surprised every time I dealt with the ICHIP people. So I'm crossing my fingers they are in charge.
I will let you know how it goes.
------------------------------
Lisa M. Lilly is the author of Amazon occult bestseller The Awakening. A short film of the title story of her collection The Tower Formerly Known as Sears and Two Other Tales of Urban Horror was recently produced under the title Willis Tower. Her poems and short fiction have appeared in numerous print and on-line magazines, including Parade of Phantoms, Strong Coffee, and Hair Trigger. She is currently working on The Awakening, Book II: The Unbelievers.
The Awakening for Kindle: http://bit.ly/15bViBm
For Nook: http://amzn.to/pFCcN6
The pricing of medical services in America amazes and outrages me. How can a Blue Cross insured be charged one price, a Unicare insured another, and an uninsured person still a third (and always much higher) price for the same service? How can we all be OK with this? (OK, thanks to the collateral source rule, there have been a couple of instances where insane pricing worked out in my favor as an attorney... but should that really be the criterion?)
ReplyDeleteTort reformers hate the collateral source rule, but I'll defend it at least as long as we have random pricing of medical services -- see, for example, http://leyhane.blogspot.com/2011/04/theory-and-practice-of-collateral.html
For the reasons you mention, it's hard to say what the real or true price for any particular medical service is. I have handled many insurance matters from the defense side and a major challenge for insurers who cover medical expenses is that in way, there is no market. Almost no one pays the "sticker price" for a medical bill, and many patients never even notice the full price if they are covered, nor does an individual patient have much, if any, bargaining power. So the insurers paying for the bulk of the services need to use their leverage to get prices reasonable. Yet, that leads to what you note -- different contract prices for different insurers, significantly higher list prices that some people without insurance pay, plus low Medicare and Medicaid reimbursement rates. I wish I knew a good solution. I'm going to check out your collateral source blog post now -- I've seen some interesting changes in that area of the law in some states and am curious what you've written.
ReplyDelete