The Gouging Is Not Enough

Someone needs to explain this country to me. I don’t understand it.

I don’t understand how we can love freedom, and yet work like mules to take it away from others, from the jailed, from the people of other nations, from our own workers, our soldiers, our students. We so love leisure and relaxation that it seems this is the only time we work this hard: when we betray our own professed morals and ideals.

I don’t understand how we can love the beauty of nature, and yet build drilling rigs atop it and rip down the centuries-old trees like grass, strip mountains down to pits of poison. How can we spend weekends watering and mowing and fertilizing our lawns and yet never go for a walk in the woods, a swim in the river? How can we pollute our own countryside?

I don’t understand why we don’t love art. We coo over talent and beauty in our celebrities — even when it isn’t actually present — and we can’t throw our money at them fast enough; but we wouldn’t pay a dime for a painting instead of a poster, nor anything for a song so long as we can download for free; and people with vast talent, who spend years striving to create true, immortal beauty, are only given one commission: get a real job. We love memes and clever witticisms, revere the turn of phrase, the surprising insight, the genuine outpouring of passion in confessions and rants and the cri de coeur — so long as it does not last more than a paragraph. And God forbid the novel.

I don’t understand why we go to war. Why we fight to protect both life, and our right to own guns. Why we eat ourselves to death, drink ourselves to oblivion, and jail those who use marijuana. Why we mock people who shop at Wal-Mart, spit on those who hold a hand out for charity, and then fight tooth and nail to keep wages low, unions useless, and education ineffective. Why we profess to love our children more than anything else — will gather by the thousands to light a candle and pray for the safe return of a single missing child — but allow thousands of children to go hungry on the streets. Why we believe the government is corrupt, even antagonistic in its self-serving greed, but trust the profit motive to build honest and effective businesses; nor why we fear the amoral inhuman corporation, but trust the government to work itself out of its shady dealings with those same corporations and their bottomless pockets without a revolution.

I don’t understand why we have not had a revolution.

But today, I’m not thinking about any of those things. Today, there is only one thing I don’t understand, and it is this: why we pay for health care. Why insurance companies are allowed to exist, and to do business the way they do. Why people work for them, even knowing what that job costs, what it entails, in exchange for a paycheck that I can’t think is more than meager.

I wonder: do the employees of health insurance companies have better coverage? Do their claims get denied? If so, do they fight? Or is the answer to this the answer to my previous question — they work for the insurance company because it is better (in this allegedly Christian nation) to inflict on others exactly what you protect yourself from?

I’m thinking about this today because of my wife. (I confess: I think about most of these things because of my wife, who is an artist, who loves nature and animals, who actually loves freedom and desires it for all as much as for herself, who doesn’t understand the same things I don’t understand, no matter how much we talk about them and try to figure them out.) My wife Toni has glaucoma. Glaucoma is a condition of the eye: the liquid inside the eyeball doesn’t drain properly, but its production continues, and so the pressure inside the eye increases steadily, causing severe headaches and damaging the optic nerve, leading to vision loss and eventual blindness if not treated. It generally occurs in the elderly, but Toni inherited it, so now she gets to be the youngest person in the opthamologist’s waiting room every few months. And though it is appallingly ironic for an artist to face a disease that could blind her, glaucoma is eminently treatable: she puts drops in her eyes every night which reduces the pressure in her eyes, and even should the condition worsen, she would not be without options — there are other medications, there are surgical options, there is marijuana. (Actually, marijuana is not a wonder treatment for glaucoma; while THC does indeed lower intraocular pressure, this effect only lasts for three or four hours per dose, and it may cause other complications that would outweigh even that benefit. But personally, I love the idea that she could be prescribed marijuana, and I could get fired for using it — even if I was prescribed it. Well — “love” as in “don’t understand and actually really hate.”) And along with the glaucoma, Toni inherited thick corneas — about twice as thick as most people’s, and so even though her intraocular pressure is much higher than most people’s, her eyes can withstand it. As her doctor told her (I swear this isn’t my analogy, but oh, how I wish it was), where most people have balloon eyes, she has basketball eyes, and the thicker walls mean they can hold much greater pressure without, y’know, popping.

So while this is bad, it could be much, much worse. She could be dying. Glaucoma threatens her vision, but not her life. Even the worst case is decades off, rather than a few years, or even a few months.

But of course, there is one thing that makes this situation much worse than it has to be, more dangerous, more frustrating, more costly: Toni is an American. We live in this country, rather than in one of the civilized nations on this Earth: the nations that pay for health care. Instead, we have to deal with an insurance company. Which is why I’m thinking about this today, why this is what I don’t understand right now.

The Affordable Care Act is four years old, now, and it has helped: millions of people are insured that weren’t insured before; the costs of health insurance and health care, while still growing, are growing slower than they have in years. And people can no longer be denied coverage because of pre-existing conditions or lifetime maximum allowances. But the ACA — Obamacare — didn’t go far enough, and now Toni has to slog through the quagmire that is left, which is deep and dangerous, even if smaller than it has been in the past.

You see, while you can’t be refused coverage because of a pre-existing condition, insurance companies can refuse to cover health costs associated with a pre-existing condition for up to a year after the initial diagnosis. Toni has been aware of her high-pressure basketball eyes for quite some time, but the official diagnosis of glaucoma, and the accompanying need for more frequent tests and for daily eyedrops, only came last May. And then in June, we moved from Oregon to Arizona, and I took a new job.

And got new health insurance.

With that came the letter informing us that the company would not cover any costs associated with Toni’s pre-existing condition until ten months after her coverage began, which deadline will be June 30 of this year. For the intervening year, in which Toni would need to find a new opthamologist and undergo new diagnostic tests to monitor the progress of the disease, and of course take medication every day, the insurance company would not pay for any of it.

So here’s my first question. Why not? Why wouldn’t a company that exists to cover medical costs actually cover those medical costs? Is it because they are protecting themselves from fraud, from the danger that her previous physician, who was outside of this company’s circle of approved doctors, might have lied, so that Toni could bilk the company of the costs of treatment? First, why would that require anything more than a confirming diagnosis from a physician they trust? And second, why would anyone try that scam with glaucoma? The tests cost money, as does the medication, but we’re talking about hundreds of dollars over the course of a year, not hundreds of thousands, as can be true in other cases.

My assumption is that the company is merely taking the opportunity not to pay out money. Simple as that. They don’t even have an excuse that has any humanity or business logic to it: they just refuse to pay money. In the past, insurance companies have refused to pay any money for any pre-existing condition; now they can only do it for a year — so they’re doing it for the year. If the law allowed them to refuse payment for three years, they’d do it for three years.

That is madness. Absolute madness. An insurance company exists to pay money for claims. They profit by collecting more in fees than they pay out in claims, which they do by insuring a greater pool; the more healthy people they insure, and collect monthly fees from, the more they have to pay out in claims, and the more money they have for profits. So the way to increase their profits should be to get more members — preferably healthy members — and to raise fees. And they do both of these things, of course — but they also fail to provide the service they exist to provide to some of their members? While still collecting fees? It’s like a mechanic taking your car into the garage, charging you $300 for a repair, and then saying, “My profits will be lower if I actually spend time and money fixing your car. Instead I’m going to inspect three other cars that are in perfect working order and send your malfunctioning car back out on the street. Will that be cash or charge?” And then you give him the money.

Exactly what business are these companies in? What does their business model look like? And is there any way to see this as anything other than extortion? We need health insurance, thanks to the obscene costs of health care in this country and the fact that our health is the one thing we can’t go without — if the car in my analogy breaks down, you can carpool or walk or take public transportation; but you can’t borrow a new pair of eyeballs, you can’t leave your body in the garage and take the public body instead — and because we have to have the service they offer, they can cheat us, openly and repeatedly, and we just have to accept it.

The most important question of all is: why do we put up with it? Why was Obamacare fought as hard as it was, and why was the single payer option — the path to the only system of health care that actually makes sense, nationalized socialized medicine — removed from the law? Why do Americans choose to live like this? All of our voices, all of our influence, all of our votes and our money: all of it is serving literally no one but insurance companies, who extort and cheat and bilk us, while refusing us medical help. Why? I remember whistle blowers publicizing the fact that insurance companies had policies in place designed to delay the payment of claims until after the person died. They let people die for the sake of profit. And yet these companies still exist? And the Republican congress tries to repeal Obamacare? If the corporations were actually people, we would charge them with murder, and we’d probably execute them; but no, we pay them more, and fight to deregulate them.

Why?

Toni got sick this past spring. Nothing terrible, just a sinus infection, but it was an extremely nasty one: she’s always had allergies, she’s always had sinus trouble, but this time the pressure was so severe that she had constant debilitating headaches, a constantly blocked airway, and a fever; she felt awful. She went to the doctor, who quickly diagnosed her with acute sinusitis and prescribed an antibiotic. Toni took the antibiotic — no treat, that, as it had unfortunate side effects that made her feel even worse than the sinus infection had — and the sinusitis cleared up. Huzzah!

Then we got the bill from the doctor’s office, for the remainder of their fee after the co-payment (That’s another one, by the way. Co-payments? We pay them to provide a service, and then we pay for part of that same service? I’ve heard of passing costs on to the customer, but this is ridiculous.). Why were we charged? Because the insurance company had rejected the claim.

So Toni called them to ask why. She waited through a long time on hold, listening to one jazzy Muzac song on a loop (Toni: “I thought I was going to have to stick a poker in my eye.”), until she got to speak to a claims rep, and she asked her question. “It was automatically rejected,” the rep said, “Because of your pre-existing condition.”

Toni asked her what her glaucoma had to do with the sinus infection. The rep agreed that that didn’t make much sense, and said she would look into it, and call back by the end of the week.

She didn’t call back.

So Toni called again. Same wait time — same damn song, threatening the same eye-poking (which would, I suppose, make the whole thing irrelevant; maybe that’s the insurance company’s ultimate goal) — and the same question. And the same response: “No, you’re right, that doesn’t make any sense. Of course the inability of your eyes to drain properly had nothing to do with the bacterial infection that got into your sinuses, almost certainly because you moved to a radically different climate and Tucson had a comparatively wet winter, which gave bacteria a perfect environment to grow and get into your system. Let me fix that and send you a check.” Well, actually, it was, “I will look into that and get back to you.”

She didn’t call back, either.

In the intervening time (Each of these Calls-and-waits-for-response is about a week’s time), we got another bill from the doctor’s office. Toni will be attending the University of Arizona in the fall, working towards her Master’s in Visual Communication. Before she was allowed to register for classes, she had to present proof that she has been immunized against measles. There’s a whole story here which I’m going to leave out, but suffice to say, she went to the doctor’s office to get her sixth lifetime measles inoculation. And then the insurance company denied the claim.

So Toni called again, this time with two questions about two denied claims. (I should note that Toni can be rather tenacious, when she thinks something is unfair. And she has worked for banks, with all of their labyrinthine procedures, and also in Accounts Receivable, where she would call the company’s clients and try to cajole them into actually paying their bills; she has said that her job was to be on hold. The insurance company holds no fear for her. But frustration — oh yeah.) This time, the rep was neither conciliatory nor helpful; after several cycles of eye-poke-inducing Muzac, the woman said that the claim was automatically rejected because of her pre-existing condition. (On a Kafkaesque note: at no time did any of the insurance company employees state what that pre-existing condition is, nor does any of the billing paperwork or our account information. Toni wondered at one point if the pre-existing condition was in fact “She is human.”) Toni asked how glaucoma could be related to sinusitis. The woman interrupted, raising her voice to talk over Toni, repeating the same statement in effect: the claim was automatically rejected (She emphasized this as though it gave her argument weight: the computer said no. You can’t argue with the computer.) because of her pre-existing condition. Toni then calmly asked why the measles vaccination had been rejected, in what way that was related to her glaucoma. There was some fumbling, but then she received the final explanation of the denial of both claims: “It was rejected because of the way the visit was coded.” In other words, the doctor had made some mistake in recording the two visits, or in their invoice to the insurance company (And just imagine how Byzantine and maddening that process must be), and that’s why the claims were rejected.

So Toni, with a furious gleam in her eye — and yet a perfectly polished and polite phone manner, nonetheless; it was like watching James Bond call Blofeld and make an appointment to strangle him before popping out to the tennis court for a quick match with his beautiful secretary — called the doctor’s office, to confirm that they had not, in fact, coded the two visits as “Glaucoma treatment (sinus infection)” and “Glaucoma treatment (measles inoculation).” They had not. So once more, she called the insurance company. This time, the rep was polite, but was also clear: the claim had been denied. Toni asked about the appeals process, and the woman directed her to the online form and explained that either Toni would have to complete it or her doctor could file it.

Then she said, “But they’ll probably deny it anyway.”

Toni wrote to the NP who had diagnosed her sinusitis to ask, just in case the company has a point, if there could be any connection between her glaucoma and the infection, if the medication lowered her resistance or something similar; he responded that there was absolutely no relevance, as we suspected. We did get a phone call the next morning, from the second woman of the four Toni talked to; she left a message informing us that the matter had gone for medical review and they were working on it constantly, without pause for breath or sleep or food (Words to that effect) to resolve the matter. She said she would call us back.

We are considering the appeal, though we expect the company would deny it, to force us to hire a lawyer and take them to court; it is my assumption that the criteria for denial of this claim was, “Could our highly paid attorneys confuse the matter sufficiently to make a jury think that there could be a connection between glaucoma and the infection?” And the answer, based on proximity of the sinuses to the basketball eyes, and the similarity of symptoms, i.e., headache in both cases, is, I presume, yes. We are also generally against frivolous lawsuits, which this instance definitely would be, considering the amounts in question. So even if we appeal, we won’t take it to court; I think the value of appealing is to reverse what I believe is in fact their policy in these matters: I think they want to make the claims process as difficult, slow, and annoying as possible, in hopes that the customer will throw up her hands and simply pay the doctor, lest she be sent to Collections by her physician’s office, with all that entails regarding credit rating and reputation. The failure to call back, with repeated promises to do so, the long hold time, the need for further review despite the obvious absurdity of their argument — and the long and complex fine print attached to the Appeal form — all fit my theory. But the most interesting thing about the appeals process? The company reserves the right to deny any claim made while your appeal is being considered. What a wonderful and terrible implied threat that is: sure, you can appeal our decision — hope you don’t get sick while that’s going on. Maybe you should reconsider, hmmm?

Why do we put up with this? Who could possibly think that the government, no matter how inefficient they may be in some ways, would provide worse service than this? I know the fear with socialized medicine is that the government functionaries would deny people health care; what would you call this? Toni had a sinus infection. One doctor visit, one simple prescription — payment denied. How would the government handle this more callously, more indefensibly, than the company? And could you imagine that the government program would cost anything even approaching what our insurance company charges us — so that they can provide us with, quite literally, nothing of any value whatsoever? We have, in essence, no insurance; certainly no peace of mind.

Why do we allow this? Why do we accept this? I know the feeling of futility that the process brings to people; I feel the same thing. But it isn’t futile: Obamacare was passed. The situation was changed. We can take this further.

We must.

That’s why I’m writing this. Not for our sake; as I said, Toni’s infection is long gone, and the measles inoculation was successful — she is still measle-free, and now registered for her classes for the fall. Her glaucoma is being treated. All told, after they deny our appeals, we will be out just over $200, which we can afford. Her time with a pre-existing condition is almost up. We can handle our situation as it stands now.

But what if?

What if we decide to appeal, and Toni gets into an accident, and they deny her claim because she is in the middle of appealing a ruling?

What if that was the claim they had denied because of her glaucoma, and we were out thousands?

What if the pre-existing condition was life-threatening and expensive?

All of these things are true, for thousands if not millions of Americans.

Insurance companies are letting us die so that they can make money. They are not making our lives better, they are not improving either our medical care system nor our health outcomes.

It is time to stop allowing our government to help them make money from our suffering. It is time we stopped this nonsense, and did what we all know is the right thing.

Please: support candidates who support single-payer government-sponsored tax-funded health care. Write to your representatives. Join campaigns to push for single-payer health care. If you have your own story, tell your own story, in the comments below or on your own blog and then send me the link; otherwise, share ours, or share another that you know with the people you can reach. Let people know that this has to stop, and we have to stop it.

I want to understand my country again. I want my country to start making sense.

And Toni doesn’t want to listen to that song any more.

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5 thoughts on “The Gouging Is Not Enough

  1. I feel your pain and can relate completely. I had to change insurance companies when I moved up here to work. At that time I went for 10 weeks without my medications because my Oregon insurance would not forward my medical records to my new insurance company. Then I went on Medicare still having my new insurance company so I was pretty well covered. When I quit my job I was strictly on Medicare but had to select a part D insurance company for medications. I did that immediately (that was 10 weeks ago). My part D insurance company has sent faxes TWICE to my doctor and they have yet to get a response back. Sooooo, I have now been without medications for another 10 weeks. I have called numerous times to the clinic where my doctor is, have physically gone there and still nothing. I am diabetic, have high blood pressure and high cholesterol. I need meds for all of this. Our health care system should not be like this. I should count…my health should count.

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    1. I agree completely. I do not mean to focus exclusively on insurance companies here; the only reason that medical procedures and medications cost as much as they do is because the market can bear those high prices — which it can because the insurance companies will pay thousands and thousands of dollars for one person’s medication. I think the care providers and the pharmaceutical companies bear their share of the blame.

      Thank you for sharing your story here. Every story helps.

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    1. Thank you– I hope so too. I believe we must fight the political narrative — the one which teaches us that, despite all evidence to the contrary, the U.S. has the world’s greatest health care, socialized medicine will be bad for us, and the free market fixes all things — with our own honest personal stories. The truth will out.

      Liked by 1 person

      1. I’m a doctor from the UK so I can agree with there. I don’t envy my US colleagues having to stay up to date on the finances of their treatments, as well as their efficacy! I agree the United States has fantastic physicians, nurses, and facilities which could be more fairly shared among the population!

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