or more accurately, Dear Staffer who is actually reading this:
My husband and I would ask that you read this and perhaps bring it to the attention of your boss. We studied the links provided (thank you, Peter Comstock) carefully. 'A Better Way' is merely an outline without any substantive fleshing out in details. The RSC document, however, is much meatier--and we found many facets of the Health Care section concerning.
I believe that we can offer a unique perspective after more than 35 years spent as consumers/subscribers of the US health insurance industry while trying to obtain care (and coverage) for a child with a congenital heart defect, a crippling surgical complication, and an array of chronic health impairments .
In 1980, when our first child was born, my husband and I were covered by my health insurance policy with the school district where I was a special education teacher. Because of the severity of our child's problems, I did not return to work as planned, but instead exhausted the considerable sick leave days I had accumulated. When it became clear that I would have to resign my teaching position, my husband closed his small consulting business and sought employment with a larger firm that would offer benefits.
I would like to share thumbnail sketches of the experiences we had over the years, in five different states, through various changes and reforms, as a family seriously impacted by the complexities of our patchwork system. We were on an anvil where the hammer most heavily struck.
* There was no 'national coverage.' Even if a major insurer was represented in every state, the coverage, costs, and benefit details varied from state to state. In one case, a major insurer withdrew all policies from our state. (Only the New York State Insurance Commissioner protected his state's enrollees by forbidding this action; our state--Arkansas-- was not so fortunate.)
* HMO: After a relocation, this was the only option for us until the next Open Enrollment period (after my gestation was complete and our second child was born.) In theory our older, disabled child could be approved for services, procedures, or specialist care that the HMO did not provide, but the financial incentive was strong for the HMO to deny such referrals. We were told our daughter could see 'an HMO orthopedist,' but he was neither Board-certified nor a pediatric specialist. We exited the HMO at our earliest opportunity.
* Pre-existing conditions: waiting periods ranged from 18 months to 2 years. At one point we carried our old policy alongside the new insurance until the waiting period could be satisfied. Fairly costly. My husband turned down some attractive job offers because we were geographical hostages, afraid to change insurers.
* Claims: Until electronic filing became widespread, I spent many hours each week filing insurance claims, copying paperwork, telephoning to correct errors, and appealing denials. It was routine to find that a large claim would be denied immediately; only if I persisted would the claim be reviewed and finally paid. BCBS of Ohio was found to be paying lower negotiated rates to hospitals and clinics, while figuring co-pay amounts for patients on the full charge shown on the bill. I found myself acting as the (unpaid) clerk handling our many mismanaged claims.
Even though electronic filing has eased some aspects of the claims process, prescribing, and reporting, it is not without problems. A mistaken keystroke has more than once resulted in an incorrect prescription dosage--fortunately caught by an alert pharmacist--or erroneous quantities. Because we no longer see the billing details, errors and oversights can occur; this is an invitation to fraud. (In the past, hospitals found that having a patient review a paper bill resulted in significant savings. Mistakes happen.)
* Association plans: Thanks to my writing (one of the few occupations compatible with my stay-at-home status) I was able to join the National Writers' Union, which offered insurance to members through an affiliation with the UAW. Unfortunately, our rates were negotiated separately, so we had few protections. We experienced several changes of insurers. (The advantage to us, personally, was that my husband was able to form his own small business again. Until that time, we were hostage to our need for family coverage through his employment.)
The major insurance companies began backing away from 'association plans,' finding them inconvenient and citing rising costs. The NWU policy changed carriers several times--and by 2002 we were paying $1200 per month for family coverage. Ultimately, the NWU was signed up with Employers Mutual--which entity turned out to be a scam. (Peter Jennings of ABC News reported on this in the early 2000's.) We had paid thousands in premiums; no claims were satisfied until 10 years after the court-ordered process under a fiduciary agent. Many victims died before they could be made whole financially.
Individual health plans: There is no 'guaranteed issue' with such plans. When the NWU could no longer offer insurance, we applied for a family policy and quickly found that not only was our daughter excluded--multiple chronic illnesses, a mobility disorder-- but also my husband--with sleep apnea and 100% compliant with C-PAP use-- was excluded as well. They were uninsurable at any price.
* Employer-based insurance: With the collapse of the NWU insurance plans, and given our inability to get an individual policy, I returned to the workforce, taking a job-share teaching position at a children's residential rehab facility. Part-time work did not offer insurance benefits unless the individual (myself) was willing to pay the full family-coverage premium. The premiums were high, so I was basically working for insurance. (It has become quite common for employers to split full-time positions, offering instead two part-time slots. It saves money for the employer--but for the worker, not so much, even with the ACA.)
*COBRA: This welcome reform was helpful when our daughter graduated from college; she was able to continue with that insurance for the mandated three years. At the end of that period, she was still in graduate school, and her only option was to seek an individual plan-- but she was still uninsurable at any price.
* High Risk Pool: Our daughter was able to show continuous coverage for a period of three + years, and it took about 10 seconds for her to obtain a Denial of Coverage from an insurer. She entered the High Risk Pool in the State of Arkansas. The problem, of course, is that these are a bad idea that doesn't work. All the 'bad eggs'in one basket' means that costs spiral ever upward, while the minimal coverage continued to erode. Enrollees were uncooperative, failing to die in suitable numbers. What makes insurance work well is spreading the risk over a large group; ALL of us, together, can take care of EACH of us. Creating innumerable separate pools encourages cherry-picking and excessive premium increases when a member of a particular pool happens to fall seriously ill. We've already lived through that scenario! It's one of the problems that led most modern, industrialized nations to adopt universal single-payer health care insurance decades ago, with the exception, of course, of the USA and South Africa. Some issues require the might and resources of the country's government in reaching a solution.
* The ACA, aka Obamacare: By the time this reform emerged from the fray, many protections had been stripped away and common-sense steps like negotiated drug pricing had been left by the wayside. Instead of tossing away the progress that HAS been made, our legislative bodies should put sensible pricing limits in place. Insurers and practitioners will still make profits. (I would point out that private insurers thrive even in countries with single-payer systems.)
Before the ACA was passed, my husband and I had entered Medicare--the best insurance we've EVER had. Operating on only 3% of its budget, Medicare handles our claims seamlessly, promptly, and correctly. We go to 'any willing provider.' We carry separate supplemental insurance and a drug policy, along with vision and dental coverage. Our children--educated, employed, and independent-- are covered by their own policies. (Our daughter, a Federal employee, has excellent coverage; she will have to see specialists as long as she lives. Our son, working for a large corporation, has insurance he calls 'wonderful.' When his fiancee suffered a stroke, it could have meant financial devastation--but it didn't.)
Although the ACA came about only after we were unable to benefit from it, we celebrate this legislation. We know that many Arkansans have found it a life-saver--at times, literally. Small business folk, craftsmen, and artists can obtain coverage. People who had put off medical care for years have been able to see physicians and surgeons. The response seems to have surprised planners--some caregivers have been overwhelmed. Arkansas is a poor state with a population that ranks low in health status. Smoking; obesity; poor hygiene and basic care; diabetes; skin cancers; pesticide exposure--all of these contribute. Life spans are shorter here.
We've seen urgent care and walk-in clinics burgeoning; the ER is no longer the only place to go. A new hospital was just built in Conway. In a state where access to healthcare is often difficult, we need more, not fewer, facilities.
I hope that you believe our government programs and policies should not be dictated by insurance companies and drug manufacturers. You are there to protect and defend people, not corporations. The proposals of the RSC represent a return to many of the failed practices that made our lives (and our finances) problematic for decades.
The nominee for head of HHS, Tom Price, does not have the perspective that I have offered for your consideration. Each Legislator is in a position to roll back real progress and return to discredited practices that burden families like ours......or, perhaps instead to seek bipartisan cooperation that improves on the partially-successful ACA.
Very truly yours,
