The insurance mess

I haven't had employer-provided health care in over ten years, which means I've been paying for individual or small group insurance for myself and now my family every month. Every year my premiums increase by 30%, so I've changed providers going from crappier to crappier policies until now we've got the cheapest I can find. This "cheap" policy is costing over $1300 a month and is an HMO, so it only covers in-network providers. Because it's not a very good insurance company, very few providers take it. For my OB/GYN I just pay out-of-pocket for my appointments.

Two things now: my pediatrician referred my son to an ear-nose-throat specialist to check his hearing. None of his referrals take our insurance, so I called the company, used their website to pick a random doctor, called the doctor and was told they didn't take it, was transferred to another doctor, was transferred again and finally ended up with a fax line picking up my call after fifteen minutes on the phone. After two hours calling various people, I gave up and am now going to pay out-of-pocket for the referred doctor for Ollie tomorrow.

Some time last week I think I stepped on a piece of glass. There's something in my heel and I've soaked it and squeezed and tweezed but whatever it is, I can't get it. It's been throbbing for a week. My primary care physician can't see me for two weeks. Their urgent care center takes my insurance but I have to make them my PCP to have the visit covered. Another local urgent care facility doesn't take my insurance. So basically if I want to address this before May 24 and not pay out-of-pocket, I need to go to the ER and it's a $50 copay.

I wouldn't even mind going to the ER except my local hospital closed and the ERs are across or uptown. Why did my local hospital, a level 1 trauma center serving an area with over 800,000 people, close? It went bankrupt. There was a New York Times article around the time of its closing stating that its ER was a dumping ground for people with no insurance because they wouldn't turn anyone away. I don't know if this is true. I don't know why they went bankrupt and suddenly closed. But it's insane that an area as dense as the lower west side of Manhattan has no hospital and that politics and money are keeping residents from critical health care services.

I probably won't go to the ER because it's not an emergency, and I don't think it's an appropriate use of those services. But my insurance and the system are conspiring to send me there. I'm not sure how that keeps health care costs down, to pay for an ER visit over less extreme types of care. I guess ultimately the insurance company saves money because I'll just walk around with glass in my foot for two more weeks. And pay out-of-pocket for care in addition to paying thousands of dollars a year for insurance.

I'd hoped health care reform would somehow solve this, but it's clear to me that it won't. The system is broken and even people who talk about fixing it don't seem to realize just how broken it is.

There are 13 responses

My only suggestion (which is rubbish) is to move to Europe. As I was reading this post, I had to google 3 terms that are unfamilar to me: HMO, PCP and co-pay. The system sounds insane and the amount of money you're paying monthly is also insane (I pay half that in National Insuarance premiums, which includes the health care contribution, a state pension contribution and God knows what else). Every time I read an article about the American state system, I am shocked that a country as well-off and as concerned about lives of people in other (*cough* oil-rich *cough*) countries is so very cavalier about the lives of its own people.

I am really sorry to read this and shocked what you have to deal with in a seemingly civilised country. Really, Europe...really good. The health care is not perfect but at least you can get treatment for things you've mentioned and it won't cost you anything (except 7.40 for prescription for adults, prescription meds are free for children and pensioners...prescription meds are also free in Scotland and Wales now). It is shocking what Americans have to put up with in order to get healthy. Just shocking.

...people who talk about fixing it don't seem to realize just how broken it is.

But how would they? They typically have money to pay for better insurance... and the connections to find better doctors and facilities.

I think you should go to the ER. that sounds pretty bad! And you are right, by the way, this really sucks. I actually can't figure out why people who want to keep the system the way it is don't really this inhibits American entrepreneurs. Not everyone would quite their jobs to start their own businesses but a lot of people might try something different if they didn't have to keep their job for the health insurance. Really, only the young and healthy can afford to take a risk (or the desperate).

AMEN! I have what is considered pretty decent employer provided (University of California) insurance and it still amazes me how many hoops I have to jump through to get treated. And I totally agree that health care 'reforms' are putting a band-aid on a bullet wound. Please get the glass taken out before the 24th... the same thing happened to me (drunken stumbling amidst shards of a broken shot glass) and I ended up with a septic infection. Seriously if you see spider webs of red from the puncture point, do not pass go. But good luck and universal health care now!

@Kinga Thanks for the support. I wish it were as easy as going to Europe. Why people are so against reforming the system here, in their best interest, I'll never understand.

@Emil When it comes to our elected representatives, I'd say it's their job to find out how broken things really are. Instead of telling us it's users of the system that are the problem, admit the system itself is not functioning. In the very least let those of us who want to access to the level of insurance we taxpayers provide for them.

@jane I agree, not only does the insurance situation deter people from leaving their jobs, it makes it nearly impossible for people to start a company and offer benefits. When I started Pyra/Blogger in the 90s we were all single and childless, so benefits were deferred for over a year. If I wanted to start a company today and hire any of the people who I'd love to work with, I'd have to offer insurance from day one. According to this American families who are insured through their jobs average health care costs of $19,393 this year, with over 50% of those costs covered by the employer. That makes it pretty hard to start a company on any kind of shoestring budget. Or as you point out, walk away from your job with benefits to take a chance on something.

@emily Thanks for the tip, I will keep my eye on it. I'm not 100% certain it's glass, I don't know what it is. I can't see it, and it doesn't look like a splinter. If it keeps hurting as much as it throbs right now, I won't be able to wait. Unless I plan on not walking for the next two weeks.

As Kinga mentioned, it doesn't have to be this bad. To me, as an Australian, everything you mention sounds so horrible. How any small business owner survives is beyond me.

Here, primary care is rebated at a pretty high percentage. Trips to public ERs are generally free and the cost of private health insurance is reasonable for those extras.

Keeping the population healthy shouldn't be an option. It's within the nation's best interest to keep people healthy and working.

John Gilmore once explained to me how he manages his health care. He's self-employed and pretty well-off, but he's also incredibly smart and very good at cost-benefit analysis. John's approach (if I recall correctly) is to take out disability insurance and catastrophic injury/illness insurance, both of which are relatively cheap. Then he pays cash for *everything* else - and negotiates a cash discount for all the services he uses. He's pretty confident that this is much cheaper than any private health insurance he'd get, and unlike an insured patient (who is a pain-in-the-ass liability for a PCP, who has to deal with the insurer to get paid), John is a paying customer with the power to take his business elsewhere, who represents cash-on-the-barrelhead for each visit, and that means his doctors treat him like a VIP, not an inconvenient hassle.

Yes, the US system is an absolute mess because we use insurance for a purpose it was never intended -- to pay for routine care. Nowhere else in our financial lives do we use insurance to pay for regular, day-to-day expenses. This article from The Atlantic will change your perspective. It changed mine:

@Michael Agreed, don't understand how this isn't more of a driver for reform.

@Cory This is an interesting idea, and maybe ok for an individual, But I'm not sure I'm comfortable with that for my children. And as someone who's not a wheeler/dealer, even the thought of having to negotiate the cost of every transaction stresses me out!

@Steve I've read that article. The problem I think is "insurance" isn't the right term for what we need. As the Europeans and Australians have pointed out, a national health care system provides a standard of service to all citizens, regardless of individual wealth or genetic predisposition to disease. Here in the US medical problems contributed to nearly two-thirds (62.1 percent) of all bankruptcies in 2007 and "More than three-quarters (77.9 percent) were insured at the start of the bankrupting illness, including 60.3 percent who had private coverage." Pretty scary stuff.

As for choosing what services to consume, living healthier, etc.: three people very close to me were diagnosed with cancer in the last few years. All three are healthy and active and had never been sick. One died within six months. It only seems fair to pay into one common pool so that you can get access to routine care to keep you healthy and productive, and when your number comes up -- and it will -- you can get the treatment you require without bankrupting your family while you die.

That is awful. I am Canadian and thankful every day for our "evil socialized medicine", especially when I am able to take my children to the doctor without hassle. Health care is absolutely the number one expense of our provincial governments and there are challenges with rising costs. But I cannot think of a better use of my tax dollars in a civilized society than ensuring that everyone who needs health care is able to access it.

Wow, I am also Canadian and while I sometimes (not often) complain about the 48% rate at which my income is taxed, I read your post and realise that I am grateful to not have similar issues. In addition to moving to Europe as an option, consider Canada too :-) I hope you can get some care for your foot soon.

Ugh, I moved to New York from Massachusetts about 7 months ago. The last thing I expected was for New York to have worse, more expensive, more complicated insurance than Massachusetts, of all places.

But the truth is, the recent renovations of MA healthcare made pricing predictable, if not glorious, and it's easy enough to get decent coverage if you have a "reasonable" amount of money to spend. Your $1300 is around what bought me "family" coverage in MA, as recently as 2010. That covered me, my wife, and any kids we have or might have. It was a reasonable plan with office copays, prescription copays, and e.g. $500 fixed price birthing co-pay.

When I moved to New York I switched to Freelancer's Union because it's the only plan I could find even vaguely affordable on those terms. The coverage is terrible, and I'll pay tons out of of pocket for anything outside of the most basic preventative care visits.

All of this just to say … it sucks, but I hear you. Suffering along with you.

I am sorry that you are going through this. You have my sympathies. My last pregnancy was four years ago and I paid 2K out of pocket for my delivery, which was a C section. This time, I will pay THREE times as much and my husband works for the hospital that I will deliver at.

Health care blows. The doctors do not make money, the hospitals do not. Do not get me started on the wonderful midwife who is about to be let go.

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