December 6, 2024
I'm going to interrupt the regularly scheduled kawaii programming to talk about health insurance. To preface this, I do not condone violence or murder. This post isn’t about that. This post is about the death of people at the hands of corporate greed. If this post is boring to you, I won’t be offended, I have plenty of other things that you can look at on this site.
Given this conversation is a hot topic right now, I'm going to speak my piece on it. I've dealt with insurance companies from a treatment provider end for almost a decade now and what I’ve seen is absolute nightmare fuel. I don't claim to know everything about every type of insurance, but I know a lot.
First and foremost, they make this shit confusing af. Don't worry, it's not you, it's them. Let's start off with some basic definitions.
- Claim
A request by a healthcare provider to an insurance company for payment on medical services.
- Claim Approval
The insurance company pays the cost of the service.
- Claim Denial
The insurance company refuses to pay for the service but gives you the option to appeal.
- Appeal
Opportunity to argue against the denial reason.
- Prior Authorization
Some services are classified by the insurance company as needing a “prior authorization”. Usually these are things like hospital stays, surgery, anything “expensive”. You know, the things you really need health insurance to cover. This essentially means that your healthcare team has to ask the insurance company if they will cover it before they move forward, unless of course you are willing to pay cash in the case the claim is denied. The insurance company will review your medical records and decide whether or not your doctor has made an appropriate determination. You're lucky if a human reviews your records, let alone one with medical experience. If the request is denied, you'll be given the option of appeal. Good luck with that.
Appeals are slow, frequently do not yield postive results and most people don't have the cash to cover treatment if the appeal gets denied so they just don't go through with it. People get discharged from nursing homes and die because of this. All the time.
- Premium
The amount you pay monthly/annually to your insurance plan. Most Medicaid plans do not have a premium.
- Deductible
Insurance companies may fully cover an annual check-up or other low-cost visits but generally, once you start going to specialists or have another expensive medical issue you’re paying it all until you reach your deductible. Once you hit your deductible your insurance starts to help pay for visits. Full coverage is not an option until you hit your out-of-pocket max.
- Out-of-Pocket Max
Once you've hit your out-of-pocket max, the insurance company is obligated to pay 100% of your health care needs IF and only IF you meet their coverage criteria. Most expensive procedures and treatments are going to need a prior authorization.
- Commercial Insurance
Most people with commercial insurance plans are enrolled through their work benefits or the benefits of their spouse or parent. The employer pays a portion of the monthly cost and so does the policy holder. This is also referred to as employer sponsored.
Some people pay out of pocket. If you aren't like rich-rich but you make "too much money" for state insurance and you're self-employed, you'll likely be stuck paying for an expensive, yet crappy plan. We will get to an example later that shows how badly this can play out.
- Medicaid
Medicaid plans are funded through the state. There are income requirements and coverage vary from state to state. Some states have Medicaid plans that provide great coverage to the patients, some states have terrible Medicaid plans. Generally, there will not be a monthly cost and co-pays will be very low.
My state requires an income under $21,000 for an adult with no children, under $41,000 a year with children. Medicaid plans can also be managed by a commercial payer. The state sets most of the rules for coverage criteria but it may default to the commercial payer if the stated has not defined coverage criteria for a given treatment or procedure. Medicaid is not the same as Medicare.
- Medicare
Federally funded, only an option for those 65 and older or with certain health conditions or disabilities. Medicare plans can also be managed by a commercial payer.
Every insurance plan is different, lets take a look at a couple realistic examples
| Employer Sponsored Plan Example | |
|---|---|
| Monthly Premium Paid by Customer *excludes employer contribution |
$200 |
| Deductible | $3,000 |
| Out-of-Pocket Max (OPM) | $5,000 |
| Total Cost by End of Year if OPM is met | $7,400 |
To reiterate, this means that you'd be spending $7,400 by the end of the year if you got to the point where insurance should start fully covering the cost of your care. Remember, this excludes the cost that your employer pays in. If they contribute $200 a month towards the premium on top of what you contribute (i.e. insurance company is getting $400 a month in premium payments for your plan), that's another $2,400. Even though you aren't directly paying that cost, it's part of your benefits package and considered part of your compensation by your job.
You might be healthy right now, and this maybe doesn't feel like a huge deal but anyone can end up with a severe health condition at any time.
If you're in the position of being self-employed, pretend you are a contractor with no kids and you make $35,000 a year, you probably won't be eligible for a Medicaid plan. The cheapest plan has a high premium, deductible and out of pocket
| Self-Employed Plan Example | |
|---|---|
| Monthly Premium Paid by Customer | $500 |
| Deductible | $8,000 |
| Out-of-Pocket Max (OPM) | $10,000 |
| Total Cost by End of Year if OPM is met | $16,000 |
If you hit a point by the end of the year where you meet your out-of-pocket max. That would mean almost half of your income went to healthcare.
If you have ever wondered why someone with health insurance doesn't go to the doctor. this is why.
Oh, and guess what? This shit resets every year.
Just like any other large company, insurance companies are always looking out for their bottom line. Company must make lots of dollars to keep shareholders happy so stock price can go up. How do insurance companies make money? They take in more money than they spend. How do they do that? if you're forking over $200+ a month for your premium on Garbage Insurance Network. You pay all your deductible and out of pocket max, when it comes time for insurance to kick in and start paying their share, you know, what you paid them to do? They say no. They have your money; they refuse to pay for a medically necessary procedure. Dollars in their pocket and a big fuck you to the patient. They look for reasons to deny coverage, not approve it.
I really hate this question. There's a misconception that it's so easy to sue anyone at any time in America. Lawsuits cost a lot of money and quite frankly are emotionally taxing. Your medical history could even become public information. Insurance companies have entire legal departments. If you are already struggling to afford your healthcare, an attorney is not going to be a viable option.
Unfortunately, the system in America is so broken that It's not that simple. Let me explain. I worked at a inpatient treatment facility obtaining prior auths for patients. Treatment providers or any other medical entity that provides a service to patients can negotiate rates with commercial insurance. The state pays a flat rate, and that rate is low.
Here's an example:
Keep in mind, these patients have no difference in treatment, in terms of the care they receive. To be clear, I'm not saying there should be any difference based on funding. That would be unethical. Also keep in mind that these facilities have buildings to maintain, doctors, nurses, 24-hour staff, therapists, case managers, supply needs and the cost of food was also included in these daily rates.
- Patient A has Medicaid (state insurance), Medicaid pays $200 a day. After only one prior autorization the patient is covered for a 30 day stay.
- Patient B has commercial insurance. This particular insurance company is contracted to pay $600 a day. The patient needs a new prior autorization every 5 days and has to leave the program after only 10 days once insurance denies additional days.
Argueably, the patient with commercial insurance is less likely to have a positive outcome in this instance.
You may also notice that the rate for state insurance is low. $200 is not enough money. How do these facilities stay open? Sure, non-profits can get grants but it's still a struggle to maintain staffing and keep up with the services on a shoestring budget. Ever wonder why the pay for social workers or anyone else in these industries is so low? This is why.
For-profit programs essentially end up staying open because those commercial plans bump up the amount of money coming in. To put it bluntly, commercial plans are subsidizing treatment costs. Even with the shorter stays. Or, they just don't accept state insurance. You should also consider that for-profit doesn't mean evil and money driven by default and non-profit isn't always good. I could write a diatribe on that alone. Maybe another day.
This extends far beyond treatment programs. I have a private practice doctor with a small clinic. I've been seeing him forever. Only 4 people work there including the admin and an accountant. He showed me his reimbursement rates for different payers. This was something that I asked to see. The state rates were abysmal. He works part time at a hospital to keep up. If universal healthcare was brought into play with no adjustments in reimbursement rates, small clinics would either go private pay/commercial payer only or shut down because the state won't pay reasonable rates. Providers and treatment programs are allowed to pick and choose what insurance they take they can always choose not to take state insurance. This would lead to increased wait times and even worse patient outcomes.
Universal healthcare does not mean that everyone would have access to the same healthcare for free. Some providers will no longer become an option. This could create a larger divide in quality of care between classes.
I'm not going to skate over the fact that there are plenty of bad actors on the healthcare provider end who commit fraud, inflate costs, spend millions on executives. Large medical groups and hospitals are notorious for this. While I'm focused on insurance here, this is also a major contributing problem that hurts patients.
To be honest, I don't truly know what the full solution looks like. There are so many components here and shit that I don't have data on. I can tell you that first and foremost, commercial payers need accountability. Not just fines that they pass on to the consumers with increased premiums.
Providers can face criminal charges for fraudulent billing practices. Why aren't insurance companies held to the same standard for fraudulent claim denials? How is taking someone's money and denying a legitimate claim not considered fraud? State plans need to up their reimbursement rates to keep small clinics open. Large hospitals need to stop price gouging on care and for the love of God, all insurance companies and large medical groups need to cut executive costs. There is absolutely no reason why a CEO of a hospital or a healthcare company needs to make 10 million dollars a year. If you concentrate that much cash at the top of the pyramid, everyone else gets screwed especially the patient. Nobody should have to die to increase someone else's net worth.
This is simple, but it might be hard. The answer is don't stop talking about it. Companies are already uncomfortable that people are having these conversations. They are trying to stop this discussion.
Write to your senators, refuse to accept that this is how it's going to be. It doesn't have to be this way. Don't let people steer you into an argument about an assassination and “humanity” towards one person. Bring it back to the core issue: corporate greed and class divide is destroying the lives of people in America. Caring about the vulnerable is the true act of humanity.
credits
pigmen: starvingeyes
emotional support animal: poomelo