J.L. POWERS

This past week, I’ve been battling the big evil corporations known collectively as Health Insurance Companies. Actually, I’ve been trying to figure out whether I should stick with my Blue Shield of California plan or switch to some other plan. The question has boiled down to this: “Which company is going to screw me over the least?” I know that I’m going to get screwed; but if I can choose the degree of screwedness, I’ll feel a little better about life.

My frustration started when Blue Shield failed to cover more than 25% of a routine gynecological exam that included doctor ordered blood tests to make sure I’m okay to get pregnant. Let me emphasize that I went to an in-network doctor and had the blood tests performed at an in-network lab. There was also no indication on the denied claim that the $900 plus dollars I was going to have to pay would be put towards my $2000 annual deductible.  The anger kicked in when I realized that I would be paying full price for the doctor-prescribed prenatal vitamins, that my insurance company wasn’t covering any of it. Okay, it’s just vitamins, not life-saving medication, I know all of that. But they’re prescribed. I remember walking home from the pharmacy with all sorts of expletives running through my head: “Why am I paying $636 a month when the  health insurance company isn’t paying for a damn thing? What’s preventing me from putting that $636 in a savings account and paying for medical bills myself? Given that I rarely visit doctors, because who can afford a doctor in today’s medical climate and also because I’m generally healthy, I’ll easily tuck away $8000 a year.” We got the insurance policy in large part because Chris put his foot down on getting pregnant without health insurance–but even he’s been pretty miffed about how little the health insurance companies are willing to cover when we’re paying that much every month so his response was, “Do whatever you think is best, I’m just worried about the birth.” But I’m not sure we’ll even benefit from the maternity coverage because I’m planning on a natural birth, midwife attended, preferably home birth though birthing center is doable, and the health insurance companies don’t cover any of that anyway.

So why not quit health insurance altogether? I’m tempted. Very. But of course, it’s the dreaded catastrophic medical emergency (something I do know a little bit about, having been hit by a truck while crossing the street in a crosswalk) that prevented me from cancelling my health insurance then and there. It’s the “something goes wrong while giving birth and ending up in the hospital ER with an emergency C-section and a month-long hospital stay” that’s keeping this policy around. It’s the whole “50% of bankruptcies in America are medically related” statistic that was thrown at me by a medical insurance salesmen earlier this week that worries me. I balked seeing how a few days at Stanford Medical Center can cost half a million dollars. (And to think, up until December, I had access to all of that highly expensive medical care for only a $20.00 copay, as long as the student health clinic referred me…)

For those of you with employer backed insurance plans, let me explain how private insurance works. Chris and I pay $636 a month. For office visits to providers that Blue Shield has listed on their “preferred providers,” we have a $45.00 copay. However, that $45.00 copay only kicks in after we have each paid a $2000.00 deductible. Even if Blue Shield does what it says it’s going to do, if either Chris and I have a lot of medical needs in any one year, the total amount that we (combined) have to pay before Blue Shield really kicks in is over $24,000. 

What does this mean? After we pay the 2000.00 deductible per person–(4000.00 for the two of us)–then Blue Shield will pay 70% of the bill from preferred providers. We pay 30% up to an additional $10,000 per person. This is called co-insurance. So, we pay a $2000.00 deductible for me, $2000.00 for Chris, then $10,000.00 for me, and $10,000.00 for Chris, for a total of $24,000. Then, if we’re still sick and needing medical care, and it hasn’t passed over into the next calendar year, Blue Shield will pay 100% of the bill as long as the doctor we’ve seen is one of their preferred providers. If we’ve been really sick, though, and already racked up all these bills, and then it becomes January, we’re subjected to that same system all over again–the $2000.00 deductible, the coinsurance, the whole ballgame. Even worse is if you’re dealing with out-of-network doctors. If we ended up getting sick when we’re visiting our parents, for example, and we have to spend time in an out-of-network hospital, Blue Shield will only pay 50% of the bill. Then, if there are discrepancies between what Blue Shield is willing to pay and what the hospital charges, we’re responsible for that, too. So let’s say the hospital bill for both me and Chris is $100,000, and Blue Shield says they’re only willing to pay $20,000 (because that’s “usual and customary,” they claim, though no one asks them to provide proof that indeed $20,000 is usual and customary compared to the $100,000 bill that the hospital is charging). In this instance, Blue Shield will pay 50% of 20,000. That means they pay $10,000 of the bill. Chris and I are left with a $90,000 hospital bill. But, here’s where things get fun. Let’s say Chris and I haven’t met the deductible yet. That means that there’s another $4000.00 that Blue Shield is unwilling to pay. So out of the $100,000 hospital bill, Blue Shield is willing to pay $6000.00, leaving us with $94,000 in medical bills.

Owing a hospital that much would easily bankrupt most middle class Americans, and Chris and I are no exception.

It’s true that I’m posing hypotheticals. But if you’re curious, there are plenty of real-life examples of people being left with exactly that much of the bill, and  you can find them with a simple search using google.

Further, as individuals, we have no power to take health insurance companies on. Unless we get a lawyer, we can’t say, “What the hell? Where are you getting these numbers for usual and customary?” Let me tell you something as well: the “usual and customary” language is a lot of baloney. Hospital stays routinely cost in the hundreds of thousands. Maybe insurance companies are going to Ecuador for their figures. Maybe it’s “usual and customary” in Ecuador for a long hospital visit to only come to $20,000–-but insurance companies don’t have to answer any questions about how they’re doing cost analysis for their “usual and customary” figures.

I’m no stranger to going up against insurance companies. When you have an employer-provided health care, you actually have a lot more power on your side than if you are one solitary person against the health insurance company. Thus, it is no surprise to me that I never had any problems with my health insurance covering things when I was insured through Stanford University or when I was insured through SUNY-Albany. I might have had to deal with small things from time to time, but I wasn’t always having to track down claims, talk to the medical provider, or deal with more than a co-pay. But as soon as I went on COBRA with SUNY-Albany, I started having problems. I didn’t have anybody to battle for me and at the time (2001-2002), I was struggling with a stress-induced lingering health problem. My physician sent me to the Mayo Clinic, an experience in extraordinary medical care  over two days with a $15, 000 bill attached. My health insurance company, which was supposed to cover 70% of the costs of my medical bills, paid somewhere in the vicinity of $2000, leaving me with the rest of the bill.

At the time, I was making $8.00 an hour, working for a literary press; my monthly salary, before taxes, was $1280. There was no way I was going to ever be able to pay that medical bill. So I got a lawyer and the insurance company agreed to settle for half of the remaining bill. My lawyer received 20% of the settlement. So I still owed the Mayo Clinic a whole lot of money, something like $8 or 9000.00, which represented 10 months of salary for me. Fortunately, I have very kind and loving parents, who helped even though I was a free and independent adult.

Here’s another thing that disturbs me. Every hour I have to spend on the phone with Blue Shield of California, my medical provider, or the billing department of the medical provider is one less hour I have to spend making money at my business. So not only am I paying top dollar for a useless health insurance policy, but I actively lose income dealing with them.

Let’s break the finances down. I’ve paid $636 a month for my health insurance policy since March. March through July, that equals $3180. I went to the doctor once, for a bill of about $1300, and I’ve been responsible for about $900 of that bill. I’ve also spent 5 hours on the phone with Blue Shield, my medical provider, and a billing company to figure out what went wrong and to try to get the claim resubmitted. Those five hours I spent with my health insurance company were five hours I could have been working. It represents approximately $200 of lost income. Ignoring the expensive prenatal vitamins, if you factor all of this together, I’ve paid Blue Shield of California $4,080 over the course of five months, lost $200.00 in income. They have paid for approximately $400.00 of one medical bill. Thus, I’ve recouped approximately 10% of what I’ve paid.

Now, I get the whole deductible applied and all of that jazz, but so far, they haven’t applied that $900 to my annual $2000 deductible. So I’m only supposed to be responsible for a $2000.00 deductible–but the insurance company gets to decide whether the $900.00 I had to pay in medical bills (let me emphasize, this bill was from one of their preferred providers) is applied to my deductible????

I’m hoping that’ll change since I asked them to resubmit the claim.

Also, for the record, I understand that buying health insurance is always something of a bet, that everybody hopes you do, in fact, lose money by buying it, that is, that you never have to use it. The alternative is never good because it means that you have had a bad accident or a life-threatening illness and, as long as the insurance company doesn’t find some excuse to drop you or not pay many of the bills, you’re covered. I understand the theory, but looking online doesn’t give me a lot of assurance that it works that way. It seems to me that I pay top dollar for a health insurance policy that *may* or *may not* cover me in the event of a catastrophic medical emergency, much less normal health needs.

My frustration with Blue Shield was so great this past week that I requested information on alternative health insurance plans. I got quotes for Anthem and Kaiser. They sounded okay–cheaper but covering around the same kinds of things or more expensive but apparently covering more. We also had a very nice, sincere health insurance salesman come to our house to try to sell us the Mega Life and Health Insurance company plan. He told us all about how Blue Shield drops patients when they get sick or finds some way to weasel out of paying the bill. He told us that Kaiser Permanente is the #1 supplier of bodies to the morgues in the Bay Area (though if they also treat exponentially more people than any other health provider in the Bay Area, that statistic is meaningless). He explained Mega’s insurance plan. It sounded so so good.  It sounded too good to be true. For example, the insurance company would not only cover our health bills but pay us $400 a day if one of us got seriously ill. The company would pay the bill 100%, in full, the day it was due so that their dickering with the health provider would not end up getting us dings on our credit scores. If we reached the age of 65 and we hadn’t used our premiums, the company would pay us the premiums back in full. For example, if we had paid $650,000 in premiums and only used $100,00 of that, the company would pay us $550,000 back. (I asked how this was economically possible because it didn’t sound right to me, and he answered that they buy insurance plans with some other company that covers it and protects their company from the risk associated with a policy like that, but it sounded a little fishy to me, the type of insurance derivatives  and hedging that got our economy so fouled up in the last ten years to begin with.) He went on, etc etc so on and so forth, and this insurance plan (“the kind our parents had, the kind we all should have”) could be ours, all for only @500.00 a month. We put in an application, he left, we went to the internet and did a search.

It took about two seconds for me to discover horror stories about Mega Life, about how little they actually cover, how it was a big fat fraud. Wishing we hadn’t put in an application (which included checks for the first month of coverage), I looked up the other companies. More horror. Kaiser has an entire web page devoted to horror stories about its medical operations, its fraud, and its coverups while so many people are fed up with Blue Cross that they literally created an organization, Sick of Blue Cross.  You know things are bad with a company when people join an organization aimed at discrediting it.

By this point, I was pretty certain that I needed to cancel my application with Mega Health and Life Insurance, but I also didn’t know what I should do with my current policy.

So I called up Blue Shield and spoke to a customer representative, posing her this unanswerable question, “Please explain to me why I shouldn’t leave my health plan with you guys and go to another company’s health insurance plan?” And yes, I outright said, “I already know you’re going to screw me. I’m trying to figure out which one of you companies is going to screw me the least. So please explain to me exactly how you plan to screw me and how you plan not to screw me so I can make the most informed decision possible.”

She was very, very nice, maybe because I used a very nice tone when I asked her my brutally honest question. I’m sick to death of health insurance companies, of the way they prey on innocent people, often very sick people, who desperately need health care and can’t afford it. I’m angry, angry to my core, at their corrupt and despicable practices. The rising cost of health care is due to a very complicated set of problems and systems, only one of which is health insurance companies’ fault. But they are part of the problem.

I don’t know a lot, but I know two things: 1) Health care is a fundamental human right and 2) our current system is thoroughly and competely screwed up. Earlier this week, I was talking to the woman who makes Catalyst Book Press’s book covers for me. She is a great designer, self-employed, and is always desperately working when I call. So she has plenty of work. But she admitted that she can’t afford health insurance and, to prevent the large medical bills resulting from a catastrophe, she’s told her family, “If something awful happens to me, just pull the plug. Let me die.”

There’s something really wrong with that picture. There’s something really wrong when two working professionals like me and Chris, who already live a frugal lifestyle, struggle to afford health insurance or medical care. (Chris has been without health insurance since 2003, and I’ve only had it intermittently during that time).  I just wish I could figure out a way to empower those of us who lack employer-backed health insurance or who lack sufficient income to either pay for medical care or pay for a health insurance plan.

I am not one of those people that believes “any change is a good change.” I’m not convinced that Obama’s plan is good enough or even good at all. Switching from one horribly broken system to another horribly broken system is completely unappealing. And frankly, I don’t trust our coddled politicians of any political stripe to figure out a system that works and that actually benefits the American people. I wish I wasn’t so jaded. I kind of think of politicians in the same way I think of health insurance companies. When I vote for somebody, the question I’m always asking is, “Which politician is going to screw me the least?”

But something needs to change. And it has to involve the whole system, not just health insurance companies. This includes the American people and their sue-happy ways. We sue doctors far too quickly and far too often. 

On the other hand, if you’re dealing with the big bad health insurance corporations, I say, “Take ‘em on. Sue ‘em for all you can get.”  The evil bastards deserve it.