There’s nothing quite like having great insurance only to find out your insurance coverage — for reasons still unknown — is no longer as great as it used to be a few years ago. Is that result the rubbing off of Obamacare on established health insurance plans that have now been debrided down to an even more lowest common denominator, or is something else stinking afoot?

A dear friend of mine hurt her back and now has trouble walking, sitting and standing. She has what is considered a government employee “Gold Standard” in health insurance.  Over the years, she has pretty much been able to see any doctor and go anywhere she pleases because all the health concerns in her area participated “in network” with her health insurance.

That’s not true any longer.

When my friend hurt her back, finding an “in network” doctor to see her close to home became a nigh impossibility. Yes, they accepted her insurance over the phone, only to find out upon arrival, in person, that they actually did not accept her insurance and so she’d be paying “out of network” — it became clear a big scam was happening to get a severely ill person to trek to an office only to be denied coverage that had previously been “vetted” and “approved” over the phone.

My friend quickly learned to force the doctor’s office to “pre-certify” her coverage over the phone before arrival to guarantee her “particular” vein of government insurance was actually accepted by her physician.

There’s nothing quite like the feeling of being “Uninsured While Insured” with no way out from the pain.

After countless tries and failures, she was able to find an “Old Skool Cool” in network surgeon who was able to see her within 10 minutes of her phone call.  It seems the older doctors are much more willing to actually take “any and all insurance” and then be able to sleep at night because they haven’t had to turn away people in pain during the day.

Once you find the right “in network” doctor, then you’re “inside” because they know which MRI center and which physical therapy shop will “take” your health insurance and that makes everything easier when you have a surgeon’s office behind you and making calls on your behalf to get you healthy in situ.

Getting pain medication is also a challenge because you cannot use an electronic prescription for a controlled substance like Percocet.  The addicts have ruined it for the rest of us. That sort of narcotic med is highly controlled Schedule 2 drug and is regulated by the Federal Government and getting a prescription filled must be done the Old Skool way with pen on paper. So much for the convenience of being in pain!

When you need to get around town — to the doctor, to the MRI station, to the pharmacy, to physical therapy, and back to the doctor all in one day — and you have a bad back and cannot walk or sit or stand for very long, you quickly realize how absolutely crippled you’d be without the Godsend that is Uber.

Sure, Uber uses surge pricing to their advantage.  When my friend was dealing with her back issues, Uber was recovering from a snowstorm and pricing for several days was stuck at 2X the base price.  A minimum surge price fare is $7 in her area and so to travel a single block costs her $7 — but that’s $7 you’re glad to pay when cannot walk ten steps alone.

I thought Obamacare was the golden pot at the end of our healthy rainbow, but in my friend’s experience, everything has changed in the couple of years since she last really needed her insurance to come through for her — and the case seems to be singularly, and more strongly, made for single payer universal healthcare coverage — because the current system is still incoherent and broken.

6 Comments

  1. I like that you are challenging business as usual. And what is now not business as usual. But I stop shy of accusing Obamacare of “causing” a degradation in insurance coverage. Businesses and the politicians that support them wholesale are savvy. They saw an opportunity to use this window of change to further exploit the system. They are hoping these stretches in predatory behaviors stick and become the new normal. So rather than socialized medicine, we how have hyper-privatized medicine where insurance companies control the process even further. The actuaries went to work like gangbusters when they saw this coming. They figure if they get to keep half the money they’re ripping out of people now they’ll be in really great shape. As for the doctors, they hate it because they’re forced to work with the short end of the stick. And the consumers, well, we’re stuck with what the Republicans demanded from this process. They took care of their buddies in the health care insurance business. They claim to hate Obamacare but in actuality that’s only to further privatize other social programs. In other words, the good intentions of Obamacare have been turned back on itself. The end game has more to do with pushing money to the biggest entities that can be found.

    1. Beautiful comment, thanks! You are right on all points!

      What’s most disappointing is that Medicare and Medicaid patients have much more free will and choice than those of us who pay for private insurance. If a hospital or a doctor’s office gets any sort of government subsidy, they are required to take that Federal insurance — they can try to limit access — but they cannot deny coverage because you’re not “in network.”

      “Out of Network” is the new boogeyman. I know people who have to foot the first $6,000.00 in “out of network” costs before their insurance will kick in and pay 80% of any ensuing bill. Now that’s fine if you’re critically injured — $6k is peanuts in that context — but when you’re seeking emergency, but routine, healthcare, that $6k can quickly deliver you right into bankruptcy.

      The whole system is a mess — and you’re right that this is all by design and plan — pretend to look open and accessible, but when anyone tries to get in the door to access services, you stop them and turn them around and send them the other way — all done with a smile and a shoeshine called Obamacare.

      You have to find a doctor who is UNwilling to play that hazardous game with your health — and, yes, they are out there — but you often have to connect directly to the doctor’s grace because the guardians at their door, and on their phones, are placed there to push away the easy-to-discourage non-out-of-pocket payers.

      1. I just want to emphasize that I do not perceive the “causal” factor driving all this to be Obamacare. All these policies emerged not by a direct product of the program, but by intelligent people gaming the system to their own predatory advantage. I’ve seen it in the way the Obamacare insurance programs have been structured. That’s what you’re alluding to. That was nothing that Obama controlled. Instead it was free market, private industry forces at work. They identify loopholes and perhaps even wrote these opportunities into the manner by which the legislation was passed and approved. Yes, there is political theater on both sides. Republicans love to hate Obamacare publicly because it gave them an opportunity to stick it to their own constituents and try to force them to go along with resistance to anything perceived to be a success on the Democrat side. That’s been the pattern with everything political. From the day Obama took office and McConnell swore to make him a one-term president, the strategy has been to make the public think all his policies are dangerous and socialistic. All the while, there have been insidious moves to enact legislation that strips basic benefits from the middle class and poor, to whom services such as health insurance are most important, with the idea that a strapped populace is a weakened voice. That forces people into submission. So I don’t buy the idea that these rates are caused by Obamacare. They are a riposte to the somewhat naive notion that the health care industry would be a willing participant in the democratization of health care. Because what we had before was not democratic, but an oligarchic and corporatized system where rates were shooting up by 12% on average every year anyway. I’ve learned to see through the surface dialogue and follow the money. What we needed was a robust public option that functions outside and in competition with the corporatized system. Of course we have that in higher education and still the colleges found ways to game that system as well. Student loans are now through the roof. The auto industry is the same way. What a car costs in reality doesn’t matter. It’s all about what you can get people to pay. That’s exactly what’s happened now with health care insurance costs. Only the system was gamed to treat everyone outside and even inside the corporate world as if they were a high risk client. The pre-existing condition clause pulls people back into the insured populace, but the high deductibles people pay basically exclude people from using insurance anyway. That’s a classically cynical and bastardly way of looking like the good guy and behaving like the bad.

        1. Yes, it’s the cover of Obamacare that is allowing this to happen. Obamacare is great for pre-existing conditions forgiveness and for catastrophic illness, but for general, short-term, emergencies, the system is broken because there’s now too great a financial advantage to force those with insurance coverage “out of network” to get them to pay full scale price, instead of the in network prorated price — just because they’re in a confused state of pain and just want the symptoms to go away. Never was a faster sentence spoken aloud than, “you’re out of network.”

          The VA is a ripe example of a wholly-managed government health services that is nill. I have a veteran friend who told me he’ll never go to a VA hospital because, “once you go in alive, you only come out dead.” We know they are backlogged and overwhelmed and we cannot have a larger version of that mess.

          The dentistry industry is the same sort of tar pit. A friend had a crown made. The flat price the dentist charges those without insurance is $1200. The negotiated price with her health insurance was $400 and the dentist’s office did not pause to tell her what a deal she was getting as the dentist was getting shorted $800 in the transaction.

          Four weeks later, that $400 crown fell out, and was lost, and had to be replaced — at a privately negotiated price of “$500!” — with the same dentist office telling her what a great deal she was getting for the replacement since they were losing $700 on the deal.

          So a $400 dollar crown and a $25 dollar co-pay results in a lost crown and a replacement for $500 and, magically, the dentist has made $925 on a negotiated insurance deal that should’ve only netted $400. Something stinks on the way to democratized healthcare and, as you so rightly suggest, we need to follow the money down the sewers because that’s where all the magic is happening out of sight.