Thursday, March 5, 2009

Health Care Reform

This is a topic that I can only discuss from my own point of view.  My youngest daughter and I have a condition that's listed on the National Organization of Rare Disorders database. We have Primary Lymphedema and I've posted about it before.

I've fought with insurance companies for treatment over the years.  Treatment that is now, since Medicare covers it for breast cancer patients, finally recognized as the best option for patients.  Still, it's not a complete guarantee.  If you go the the National Lymphedema Network's page and click the the FAQ tab, one of the choices is insurance issues and there you will find an insurance appeal letter that you can copy, add your name, your doctor's name and the specifics of your case to send to your insurance company if you've been denied coverage for compresion bangages or garments. 

Despite the fact that researchers dealing with this disorder will describe it as a chronic condition that requires daily maintenance, part of which is the aforementioned compression garments, insurance companies routinely cover only one or two garments in a calendar year.  This is something that my daughter and I have to wear every single day.  How long do you think a pair of socks would last that you wore every day, washed, dried and wore again?  Think you could make the one pair last 6 months?  It's absolutely unrealistic.  But, it's something that insurance companies do all the time.  Put it this way.  If you or someone you know is diabetic, wouldn't you be raising all kinds of hell if they told you that they'd only cover enough diabetic supplies to see you through 3 months?  You'd have to pay for the other 9 months.

My daughter was just fitted for a new garment.  It cost us $254 and small change.  That's our annual deductible.  Actually, "our" is a misnomer.  Every person in our household has a $250 annual deductible.  So, even though I need a new garment as well, I'll be waiting until April.  Imagine if you had to pay that amount out of pocket at minimum 4 times a year.  In our house, it's actually 8 times a year. The manufacturer will tell you that to get the optimum use of your garment you should have two at a time. One worn, one hanging to dry.  I've never been able to do this.

We are extremely fortunate that our insurance will allow us, once we met our deductible, to get as many garments as we need.  This is the first time I've ever had this experience.  It's still so new that I can't bring myself to use it for fear of being denied.  Added to that is the fact that we have exactly one provider that will fit us for the custom garments we need.  All the others will no longer provide custom garments.

This brings me to the crux of what I think the real problem is with American medicine.  It's a business run by the insurance companies whose goal is to make the most money from your premiums they can while spending as little as possible on you the actual customer.  The companies that have decided to stop providing custom garments are doing so because insurance companies are not covering them at anything near to their actual cost.  They are in effect losing money every time they sell one.  This is ridiculous.  It's one of the reasons I believe that insurance companies were so reluctant to cover the therapy for lymphedema.  It's labor intensive, requires the use of expensive materials and just plain doesn't meet the bottom line for their shareholders.  Which is so completely wrong.

Chronic diseases are expensive.  Improper treatment of chronic diseases is even more expensive.  Take diabetes. A great deal of diabetes is completely preventable.  But prevention is not something that brings in the bucks, so insurance companies ignore it.  Once a person is diagnosed with diabetes, they have to learn an entirely new way of living. If it can be managed with diet and exercise, all well and good.  But if it can't or a patient either can't afford the supplies to control the disease or won't control it, they end up with some really serious complications.  Expensive complications.  Amputations, blindness, and renal failure to name a few. I worked as a dialysis tech at one time and medicare provided the coverage for most of our patients.  But Medicare had a set dollar amount they would cover.  And it really wasn't enough to cover the expense of treating the patient.  Where were those costs recouped?  From the private insurance patient who insurance was billed substantially more than Medicare.  It as also recouped by manipulating nurse and tech coverage so that we technically met the minimum state requirements but only just barely and often by counting the nurse as a tech to meet the proper ratios.

Another example of the business model gone wrong is prescription drug coverage.  I have hypothyroidism.  It means I have to take synthetic thyroid hormone every day.  For the rest of my life.  I've been on daily medication for almost two decades.  In that time, I've been on several insurance plans.  When I first started taking Synthroid, I paid $7 a month.  That was my prescription co-pay for a non-generic drug.  Gradually over the years, that co-pay has risen.  Now, I pay $22 a month for a prescription that I could buy outright for $27.  All because the standard drug to treat hypothyroidism has gone from a non-generic class to non-preferred name brand.  Or as Blue Cross puts it, in the top tier of their three tier system. Yippee! This, my friends, is a crock.  And Synthroid is a relatively inexpensive drug. There are others much more expensive out there that  must be a real financial burden on their users.  I don't want to argue the validity or efficacy of generic versus name-brand drugs.  But it seems to me that drug companies are making an awful lot of money.  Yes, they need that to research new drug therapies.  But I find it hard to feel sorry for a pharmaceutical company that whines about generics undercutting their revenues when all they're using those monies for is to find a better pill for erectile dysfunction.  And don't even get me started on insurance companies that cover Viagra and its brothers but not birth control.  Do they not see the disconnect?

But seriously, how can we spend the most money on health care of any developed country and still have over 45 million Americans without health coverage?  This makes no sense to me.  Recently, I've heard Rep. Zach Wamp (R-TN) state that health care is a priveledge not a right. So says a man who has no health problems and a health plan provided by the government.  And indeed those that can afford the best coverage or to pay out of pocket, get the best care.  But it doesn't make it right. Doesn't the Declaration of Independence say something about life, liberty and the pursuit of happiness?   Or to quote Mr. Jefferson:

We hold these Truths to be self-evident, that all Men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.

How can Rep. Wamp say that health care is a privilege when faced with these words?  Moreover, how can he tell a patient who's doing their best to take care of themselves and remain productive (i.e. paying taxes) that what they need to do so is a privilege that they're going to have to a pay out the nose to maintain?

I don't know the answer to our broken health care system.  You hear alot about how awful Canada and Great Britain's systems are and how anything that puts the government in charge of your health care will be just as bad.  Seems to me if those systems don't work, why not look to ones that do instead?  And is ours, as it stands now, really so superior that it doesn't need fixing?  Tell that to the 45 million plus Americans who have no insurance and are only one catastrophic illness or accident away from bankruptcy.  Better yet, tell that to the under-insured who are in the same position.

Frankly, anything that improves the current state of affairs is a win.  But it must not overlook those of us with chronic or rare disorders.  Every time I change insurance, I worry that some pencil pusher is going to label my lymphedema a preexisting condition. The whole idea of "preexisting" conditions being disallowable has got to be some sub-human's idea of cost saving.  And again, it goes to the idea of medicine as business and health care as privilege.

I look forward to learning more about President Obama's health care reform plans. This reform is over due.  Let's hope that the ideal of capitalism run amok goes the way to the dinosaur and we end up with a stable, fair and reasonable system that meets the needs of all Americans.


Aliceson said...

1 garment a year? That is ridiculous!

My husband takes a daily medication for his narcolepsy (an odd disorder that makes him fall asleep anywhere, anytime) at first it was covered by his insurance. We had to pay about $100 each month as a copay but then the teir changed and the insurance company decided they wouldn't cover it anymore. After about 6 months of paying full price and getting every sample the doc would give him, while sending letters and diagnosis from the doc., we now only pay $40 copay each month but the actual monthly cost of his medication before insurance is almost $600. Sounds more like Highway robbery than health care!

skyewriter said...

The racket we think of as healthcare in the US is a joke.

Pre-existing conditions are just a way to deny people coverage (and in reality it ends up being a class issue).

I posted that same video yesterday on my blog (kizmet; or perhaps just infinitely pissy-offing).

Healthcare in the US is a privilege not a right?

That's what is so very wrong about the rightwing thinkers in this country.

If you aren't the right [insert color, sexual orientation, religion, political party] you don't deserve to be equal.

Petra a.k.a The Wise (*Young*) Mommy said...

It is unbelievable and I can feel your pain. I am on two medications that my insurance BARELY covers and our prescription costs are ridiculous. I also have infertility issues and of course, insurance pays very little for treatments if I need them next time we go to conceive.

I am hoping that we do get some reform with Obama. But I am not holding my breath.

Wild Child said...

And I don't understand why people always put down social health systems. I used the British system when I was living there as a student. I had no trouble getting in for an appointment and getting my prescription and it was all already paid for! I did pay some poll tax for living there and definitely value added tax.

I don't understand why people yell about taxes, because they do actually go to something. If you don't pay for health care through taxes, like so many other countries do, you *will* pay for it in one way, shape or form. So many people with chronic diseases end up footing the bill, which could be spread among so many other healthy people. I guess I'm just not selfish that way. If I pay tax money that helps someone get a job, get better health care, or better education, I am not complaining. If I pay tax money for a war that I didn't think should have started in the first place, well, then I'm going to scream bloody murder.