Patiently awaiting the Golden Years

Health insurance: The big lie

By Randall Poulton | Feb 15, 2019

I know a lot about health insurance. I became an expert the hard way: I got injured and then, a year later, I got sick. At least for me, what I believed about my health insurance and how it really worked are light years apart. For this story I will call these differences “lies” because “lie” is easier for me to type than big words like: misleading, half-truth, deceptive, dishonest, and intentionally obscure (as in buried in the fine print and/or requiring a specialized vocabulary). Plus, I am frustrated. And calling someone a liar makes me feel better.

To protect me, and this newspaper, from any blowback, I will not name the insurance companies I have been fighting with during the last two years. Here is what my painful, two-year saga has taught me:

Lie No. 1: If you like your doctor you can keep your doctor. This is probably true if you are very rich and cost is not a consideration. For the rest of us, the insurance company decides which doctors they will pay for; i.e., which doctors are “in network.” The list of doctors that are “in network” depends on where you live, specifically your ZIP code.

My 2017 insurance company assigned Dr. Read in Stockton as my primary care provider (PCP). They even embossed his name on my insurance card. Never mind that I had a 30-year relationship with Dr. Berger in Bangor. And, never mind that Dr. Read was not taking new patients! My ZIP code was 04496 and, therefore, the insurance company decided Dr. Read was my PCP.

Incredibly, this was done without my input or knowledge. The insurance company never asked if me if I liked my doctor (Dr. Berger) or if I wanted to keep my doctor. Nor did they tell Dr. Read he had a new patient!

Lie No. 2: Health insurance is affordable (as in the Affordable Care Act, also known as Obamacare). This is the biggest lie. I buy my insurance through what is called “the market place.” Policies purchased through the market place are subsidized by the government, supposedly saving folks like me money.

For 2019, my insurance premiums are $1,030 per month (that’s $12,360 per year!). After the subsidy, called advanced tax credits, is applied, I actually pay about $300/month or $3,600 per year. Not too bad, I guess. But the subsidy is only an estimate: I may have to pay more, possibly the full $12,380, when I file my income tax return.

The real kick in the pants is, for $300 a month, what I get is a “Bronze” policy that covers almost nothing. To use an analogy, you could spend the same amount each month and lease a pickup truck. In which case you actually get a nice, big truck to drive. With my Bronze health insurance, the $300 a month gets me a used bicycle at best.

Lie No. 3: If you get sick, your insurance will pay the doctors’ bills. A classic half-truth. You are going to pay for a lot of things and it can be very expensive. My deductible is $4,200. So, at some level, I guess I knew I might have to pay out of pocket for the first $4,200 of health care.

But the reality of writing huge checks to various providers (“providers" is what insurance companies call doctors) was a separate pain with its own debilitating consequences. Yet, there was some comfort in “knowing” that, in the worst case, I would “only” be out-of-pocket $7,800 (premiums of $3,600 plus a deductible of $4,200). Right? Nope.

Lie No. 4: Once you meet your deductible, your insurance company pays the bills. Do you understand co-insurance? I didn’t. Here is the way it works: Once I spent the $4,200 out of pocket to meet my deductible, co-insurance kicked in and I “only” had to pay 40 percent of my bills. So, when you add my co-insurance responsibility, my real deductible, what the insurance company calls my “maximum out-of-pocket,” is $7,900. Please refer back to Lie No. 2. Do you think $3,600 in premiums plus $7,900 out of pocket is “affordable”? For the math-challenged readers, that is $11,500 per year. And it gets worse.

Lie No. 5: My out-of-pocket maximum is $7,900. It is not! The “affordable” used bicycle policy I bought does not cover eye care or dental care. Nor does it cover any service rendered by out-of-network providers (out-of-network providers are all the rest of the doctors not deemed “in-network” by the insurance company).

With the policy I had for 2017, no doctors in Bangor were “in-network.” None! Therefore, I ended up paying a surgeon I trusted in Bangor to fix my hernia, rather than waiting an extra couple of months, and driving more than an hour, to have a doctor I did not know do the surgery in Augusta. I liked my doctor and I kept my doctor: It just cost me thousands of dollars. So wrong!

Lie No. 6: You get a free annual physical. What you get for free is called a Wellness Check. It involves talking with your PCP (or their assistant) for a few minutes while they take your temperature and blood pressure.

My friend said his doctor actually used a stethoscope to listen to his heart and lungs. My PCP did not touch me with her stethoscope, nor did she do any of the other hands-on checks that used to be routine. There was no blood work or urine test. You have to request these sorts of tests and, if you do, you will have to pay for them. The entire “exam” was conducted with me fully dressed.

Maybe my PCP used her X-ray vision to check my skin for moles and rashes? When I mentioned I had gotten several tick bites, she lectured me about the over-use of antibiotics (e.g. Doxycycline) as a proactive treatment against Lyme disease.

I later got a bill for $120, which I contested because the annual Wellness Check was advertised as free. My provider explained the Lyme disease discussion was not covered under the scope of a Wellness Check. No, I am not kidding!

There is an incredible irony to lie No. 6: One of the cardinal principles of Obamacare was, by making annual physicals free, people would get check-ups and small health problems could be addressed (cheaply) before they became big, expensive, problems. Maybe No. 6 is really the biggest lie!

During my two years of extensive interaction with various health care providers, I met many kind and caring people. When appropriate, I asked providers their opinion on the state of our health insurance and health care systems. Based on the answers I got, you would have thought I was asking a bunch of Democrats how they feel about President Trump. Nary a positive word was spoken.

The general consensus is that health insurance companies hold far too much sway over what doctors do and that getting answers from insurance companies takes far too much time. Time that doctors should be spending treating patients. And that’s no lie!

Randall Poulton lives in Winterport. His columns appear every other week in The Republican Journal.


Comments (1)
Posted by: Kevin Riley | Feb 16, 2019 11:22

Not surprised at all.

https://www.internationalinsurance.com/news/ranking-top-eleven-healthcare-systems-country.php



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