THIS is the difference between Healthcare and Health Insurance
Last week I received a 400.00 bill from my children’s pediatrician. Confused, I called the Doctor’s office and was informed that our insurance provider had denied the claim.
Now, before I continue, let me say that we are extremely fortunate to have – what most people would consider – excellent insurance. This wasn’t always the case, for there was a time when Mr. Pandora and I suffered through the hell known as individual health insurance. And for those of you who have never experienced buying your own insurance allow me to educate you on the scam it is and how you could find yourself in this predicament overnight.
First, for all the praise lavished on small business as the backbone of our economy most people do not realize that a lot of small businesses are one employee illness away from losing their group insurance. And that’s exactly what happened to me, and up until I found myself in this situation I had barely given health insurance a second thought.
In the early 1990s I worked for a thriving small, Delaware business that employed approximately 200 people. It was a young industry, with a workforce whose average age was 30. In other words, we were an insurance company’s ideal demographic. Things were going great until one employee, a young woman, developed a life threatening condition and actually used her health insurance. This is where the nightmare begins.
For several months everything remained normal, then the time rolled around to renew our plan with our provider. For those of you not aware, this procedure occurs every year. Imagine our surprise to discover a 30% increase (maximum increase allowed by law) in our rates – an increase not everyone could afford. One by one employees dropped out of a plan they could no longer afford, until the insurance company informed us that we had fallen below our participatory number, no longer constituted a group, and that they were dropping all of our coverage.
Let’s recap. Small business group Insurance = one illness = 30% rate increase = loss of participants = no longer considered a group = No health insurance.
In all fairness, the insurance company did offer us another option: Fire the sick employee. If we got rid of the sick employee then they wouldn’t get rid of us. We kept the employee – an act I’m very proud of – and lost our health insurance. And don’t kid yourselves by thinking we could simply choose another provider. Pre-existing conditions are what leads to cherry picking. Overnight it was every man for himself. Overnight I went from insured to uninsured, and since Mr. Pandora was self-employed at the time I was the one who carried our benefits.
Now being young (28 at the time) and healthy meant that finding affordable, individual health insurance was easy – at least for the first year, until renewal rolled around and we were once again faced with a 30% increase. When this happened we would shop around, find a new provider with a better rate, and wait until the renewal period returned and forced us to complete the process again.
Thankfully we both stayed healthy, so insurance hopping wasn’t too difficult. But then we did the unthinkable. We decided to start a family and quickly learned that we were now prisoners to our health insurance. Most individual health insurances (if not all) require a waiting period before covering pregnancy – anywhere between 12 and 18 months in the 1990s – so we understood our days of insurance surfing were over. Our rates would increase 30% before I was even pregnant, and if we wanted coverage we would consign ourselves to the role of hostages and pay the bill. Which we did.
Luck was on our side again when, after the mandatory waiting period, I easily became pregnant. However, during my pregnancy another renewal cycle passed complete with another 30% increase. We were well and truly stuck. (Pregnancy is the ultimate pre-existing condition.) So we continued to pay a health insurance bill that rivaled our mortgage payment and found creative ways to lower our monthly premium. Did you know you can lower your rate by increasing your deductible? Pretty nifty. In the three years between the birth of my son and the birth of my daughter our deductible went from 200.00 to 2,500.00. In essence, we ended up with very expensive catastrophic health insurance – that fortunately we never had to use – while paying for every doctor’s visit out of pocket.
Why not drop the expensive insurance after the birth of your son? Not so easy since we wanted another child. And not that it’s really anyone’s business, but the three years between my children was supposed to be two, only nature wasn’t as accommodating this time around.
Another recap: Son born in April 1994 + Advised by insurance provider and pediatrician to wait until child is 6 months before switching insurance due to any illness/condition that may be contributed to birth and thus risk being classified as a pre-condition and therefore might not be covered by new insurer + 12-18 month waiting period for pregnancy for new insurer.
So by switching to a new health insurance provider I wouldn’t have been able to try for baby #2 for at least two years. Given the unintended three year spread this might have been our best option, and I shudder to think of all the money I could have saved during this time had I been psychic.
But we didn’t switch and when my daughter was born we faced our first crisis as new parents. Pediatric Cardiologist are really scary words. They also meant that we weren’t switching insurances any time soon. And so we payed our monthly premiums which were now more than our mortgage payment, held a 2,500.00 deductible for each member of our family, and payed for every well baby visit and immunization out of our own pockets. Until…
Until, Mr. Pandora finished graduate school and landed a great job with a great, big company. Talk about celebrating.
And then last week I received the 400.00 bill from my pediatrician. Seems my great insurance ain’t so great anymore. You see, they’ve changed their policy. Children over the age of six may now only have a check-up every two years. Are you kidding me? Children can’t even enter school or play sports without a current physical. And what responsible parent wouldn’t want their child to undergo a check-up every year? Yet again, we are fortunate. We can pay the bill. I wonder how many others can’t.
Starting to see the difference between healthcare and health insurance? They aren’t remotely the same thing.
Tags: Health, Health Care
Yours is a story that’s all too familiar in these United States. Too bad Republicans/Conservatives don’t give a damn and would rather mock such stories and tell you to “get over it” and “suck it up.”
I am finding it alot cheaper to just pay for things out of pocket and hope that nothing big happens.
Since I have a pre-existing condition, which is actually more expensive to diagnose than to maintain, I will be screwed if i try to get new insurance in the future.
Medical insurance is starting to insure that they get their money and nothing else.
When Republicans talk about health care what they are really talking about is health insurance.
Every year we pay more for health insurance and receive less care. And when you speak to small business owners (and I know a lot of small business owners) one of their main concerns is affording healthcare.
Brian, I am so sorry you’re in this situation. Hopefully something will be done about healthcare soon.
We are both going to be completing our education within the next two years.
The future isn’t so bleak for my wife and I… she will complete her education and start in her career field in a year and a half, I will start in my career in May.
Both occupations will have the ability to work with large companies that can afford insurance…
The bigger question is that there are people like me out there, with afflictions resulting from the growing obesity epidemic, who will not be as fortunate as I to have the GI Bill to put them through college so they can land a job with those larger companies.
Sure.. I can hit the gym and lose most of the severity of my sleep apnea as the weight drops off.. but who wants to be the fat guy at the gym?
Between me and my wife we pay $5,335.00 for a family of three with a $3,600.00 deductible. $8,935.00 a year out of pocket! Then we including all of you provide healthcare for Minner and the legisalors and all public workers. Also, we pay toward those on welfare and making sure every child has healthcare.
There will come a time I doubt if I can afford healthcare ! McCain wanted to tax the portion my employer paid!
Mike Matthews // Nov 15, 2008 at 1:14 pm
Yours is a story that’s all too familiar in these United States. Too bad Republicans/Conservatives don’t give a damn and would rather mock such stories and tell you to “get over it” and “suck it up.”
Mike, I proposed a Universal Plan called Delacare. It would have worked for Delaware.
I bet neither Obama nor Markell will do anything like it.
Thanks
Mike,
I wouldn’t say you’re an “average” Republican. Maybe I should rephrase: You’re not a “conservative” on the issue of health care. And that’s a good thing.
Now you are beginning to understand what the problem is with GM, Chrysler, Ford and all business’s. The US simply cannot compete in the world economy when all civilized and industrialized nations who have health care have a ‘SINGLE payer system”. All the new technologies are coming from those nations. We are 48th in the world….the only nation that has a for profit system.
And no Mike we don’t want your damn Delacare which was never vetted, never stood the test. Only single payer health care SB 177 and HR 676 have been peer reviewed nationwide and that is the only method that covers medical, dental, nursing home, prisons, drug treatment and every other health care isse and in Delaware would have covered everyone and still saved the State $4,000,000!
You won’t get it from Jack Markell who is up the butt of the Delaware State Chamber and the Delaware Public Policy Institute, two of the worst lobbyists against universal health care in this State.
Mike is right about Obama nor Markell will offer up a universal health care plan. Both used the
“buzz words”, but in reality will tinker with the system rather than throw the for profit system out. Everyone of the car companies in trouble today are plagued with huge health care premiums to these for profits…who make a profit while cutting services, demanding higher co-pays and none of them cover mental or dental.
If you progressives had gotten on the band wagon in the primary and pushed for it as hard as we did wind power…there would a higher probability they would at least look at the system.
We still have time to demand they hold hearings on the bill, lay all the cards on the table and when those politicans see what the advantages are, we might have a real opportunity to finally see the light of day.
Next year your co pays are going to double, you will pay more for prescriptions. Doctors in Delaware are also pushing for the single payer method, because they wont have to pay the millions of dollars in malpractice insurance, and they won’t have to pay for several clerks who do paperwork. Most of the paperwork that is turned in is sent back because the clerk put in the wrong code…then its rebilled. Doctors often don’t see a penny for 18 months after they delivered you your service. The Veterans could go into this system not having to go stand in line at the VA, they would be covered just as you and I. The elderly who have no dental care would. Right now the medicaid in the State of Delaware is being cut off. Many are being thrown off the roles. Delaware’s medicaid does not opt for dental coverage therefore the disabled, elderly are not covered for any of that. The disabled will become toothless as there is only ONE dentist in the State contracted with the State to provide the service. This horror called a dentist is known for knocking patients into severe unconciousness before he treats them. Hundreds are on the waiting list and his answer…pull their teeth out…all of them. In my sons group home two clients have already had all their teeth removed…these guys are in their late 30’s. This is a shame and a disgrace.
Markell is as we know tied to the Chamber of Commerce who sells the absolute worst insurance in the State. His plan is the Mitt Romney plan for Massachusetts, which is now bankrupting their system. Is that what we want in Delaware or do we want Jack to do the right thing for our citizens and our corporations and get health care that is proven to be affordable, and universal?
Pandora,
As an employer I am familiar with the way your insurance company operates. Our premiums are up 18% this year for the second consecutive year, and the advice the we get when we ask what we can do boils down to – don’t hire older people or young women who might get pregnant – OR pass on the increases to employees by jacking up the deductibles.
The Insurance company’s perfect small business is one entirely composed of 20 – 30 year old single men who never go to the doctor.
On a side note I had a friend with French citizenship who felt his ears stuck out too far.
He signed up to have the cosmetic surgery done and had to wait two years for it, but when it was done it was 100% paid for.
What’s he look like now?
Jason: That’s an interesting story. Now, in a single-payer system, do you believe that the government should be obligated to pay for cosmetic surgery?
I think it will be longer than we like before our healthcare system gets fixed. I keep hearing our politicians talk about universal insurance. What we really need is universal access to affordable healthcare. All the plans I’m seeing right now tinker around with getting more people covered by insurance. I guess it’s better than nothing but it perpetuates the for-profit healthcare system.
As it happens, I (very reluctantly) changed my mind, and decided that a federal government-run single-payer system is what we have to do. But I am not so foolish as to believe that such will improve our health care in the least: see this and this and this and this.
(With all those links, this’ll surely hit the moderation queue! 🙂 )
There simply is no free lunch: if we get a single-payer system, we’ll all have to pay for it, whether we can afford it or otherwise. And, as is the case in other countries, the government will have to pare back benefits because some things simply can’t be afforded.
A lot of you live reasonably close to the City of Brotherly Love. In Canada, the wait to get an MRI or a CT scan can be several weeks, yet if you listen to the Philadelphia radio stations (at least some of them, like The Big Talker, AM 1210) you’ll hear advertisements for private companies trying to get you to get a baseline MRI; under our for-profit system we have so many MRI units that they go begging for customers!
Well, take the profit out, and watch quality decline, and decline rapidly.
Don’t hold your breath folks remember a good Health care plan was put forth by Clinton with the help of Hillary the congress at that time was controlled by the Dem’s and Senator Mitchell and congressman Foley didn’t lift a finger to help. Go see Micheal Moors film SICKO it’s about folks who have insurance
Man oh man.
Now I know what I sound like when I turn everything to how much Mike Castle sucks.
Just like TT when he turns everything to how awesome Hillary is.
Dana – Define quality. What measuring stick do you want to use?
Let me also say that there is a real possibility that single payer healthcare also has the ability to save our economy. Not only is it a boon for big business, but it may provide the activation energy required by people that want to start a business, but don’t want to risk their families health.
The one time SC GOP chair, Dave Burris, has linked to this article by Will Wilkerson who says, “Economic growth requires dynamism,”
So since, as LG points out that our system puts a damper on is dynamism, since people have to stay in bad jobs for the health insurance – I guess it follows that Burris supports single payer.
What is the Republican plan for Healthcare? Do they really even have one? I mean a serious plan, not 5,000.00 paid directly to insurance companies and then taxing your benefits. No one took that nonsense seriously.
Whoever gave that plan to McCain killed his campaign (maybe more than Palin).
My Republican in laws, for example, said “I can’t have my insurance taxed.”
“I had a friend with French citizenship who felt his ears stuck out too far. He signed up to have the cosmetic surgery done and had to wait two years for it, but when it was done it was 100% paid for.”
Should Obama elect to have this ear procedure, and it’s covered by the federal government, we can expect a minimum of a 50% increase in our taxes.
I’m not as worried about the ear procedures as I am about all the fat Republicans getting their free Rascal Scooters.
That will break the bank.
In other countries it a triage system. The sickest get help first. The same exists in hospital rooms today. If your having a heart attack you are taken first over a broken arm or a cut or something. When Canada first went single payer it was done in one Province. Everyone else elected to keep what they had. After two years when the numbers came in and the Province did so much better than the others…they whole country elected to go for it.
No one is waiting in line for months…thats a republican hit piece. Ask anyone who has traveled to Europe. The hospitals don’t even have a “billing dept”.
Imagine if corporations did not have to bargain with for profit health care (often choosing companies that have huge deductibles,) wont pay for pregnancy or pre-existing conditions) who cherry pick the employees for the healthiest, and those unhealthy are on a list to be laid off to keep the premiums down…imagine if your company didnt have to consider any of that, and you got a well deserve cost of living raise…Single payer doesn’t break the bank, it saves money, and jobs. For profits are stealing 35-40% right off the top for their administrative costs, giving CEO’s huge 6 figure salaries. They hire “beancounters” to fight your claims and when they win..the beancounter is given a bonus. The for profit system put in place by Richard Nixon was never to offer good health care only the very basic with a for profit margin.
We have waiting lists in the U.S. How many times do you get in to see your doctor the same day? Isn’t that waiting?
One thing that bugs me about they way Republicans discuss healthcare is that they try to argue that we’ll have a system like France’s or like Canada’s. Can’t we learn from those systems, and pick the best parts while discarding the parts that don’t work as well?
Why is having excess MRI machines a good thing?
Truth is… we wait for all our medical care, and a lot of times are denied care. When was the last time you saw a specialist without a referral?
As a grad student at UD, the “insurance” they offer is horrible (especially when you consider my stipend from my research asst. barely pays for my bills, and I still live at home!)
But here’s what I got a kick out of, many “older, wiser blah blah blah” people tell my generation that we’re silly for thinking that just b/c we’re young and healthy means we don’t need insurance. (To be honest, I’ve never met a person in my generation that thinks that way…) And then when the insurance reps come to speak to Graduate Students last year, they say, we opted for this option fro Graduate students because you’re generally the healthiest… WHAT?!
Unfortunately, because of HS soccer injuries and severe TMJ I’m not the picture of healthy for my generation– but it doesn’t matter, MRI’s, CT scans and RXs they’re all necessary– and I have no coverage… (And even when I did, I was fighting the insurance company)
So I definitely feel you guys on the health insurance system… or lack there of– I want preventative medicine… because maybe I wouldn’t be in my situation if my parents’ insurance was proactive and not reactive when I was younger.
Republican idea of health care…to pay for Viagra but not for Albutriol for asthmatics!
I had an aunt and uncle who lived in England from 1986-1993 or so. My uncle grew up in Scotland and had lived in England for many years. My aunt moved from Delaware when they got married.
They had two sons, one in 1991 and another a year later. My aunt roundly praised the care she received at the hospital and before and after they were born. She didn’t have to wait months for a doctor’s visit. Nothing cost her a penny, or a pound.
I’m not saying the English system is perfect, but, as others here have said, we should be able to learn what they do right and adapt if for our purposes.
“No one is waiting in line for months…thats a republican hit piece. Ask anyone who has traveled to Europe. The hospitals don’t even have a “billing dept”. ”
AMEN to that. I am from Berlin, Germany. I have lived in the United States for over 14 years now. I never had to wait for medical procedures in Germany nor did I have co-pays as high as here. Yes, we have taken money out of our pay checks to pay for health insurance; however, that money has always been taken out, so you don’t really notice it. It would be different here, where not everybody has it taken out of their pay.
Additionally, my company in Germany also paid part of any left-over cost. When I needed major dental work (I lost my front teeth in an accident at age 14 and needed to get a Bridge to cover the gap), my insurance paid about 30 to 40 percent of that cost – my employer paid 80 percent of what was left. Why? Because I had to interact with clients and how would that look if I had no teeth or bad teeth? I paid a very small portion – about 300 dollars, out of a bill totaling roughly eight thousand dollars. This made me appreciate my employer A LOT.
The European health care system is NOT IN THE LEAST the way that the conservatives here in the US make it look/sound.
Also, when I lived in Germany, my portion of the health insurance was half of the total premium (about 12% of my income – the current rate is about 15% – see more at http://www.howtogermany.com/pages/healthinsurance.html)) – at 1000 dollars that would be $120 – about half of that was paid by me, the other half by my employer). During my employment with a non-profit here in Delaware, my paycheck came to less then $1000 every other week yet my part of the health insurance came to close to $300.
The link above is pretty detailed – it also tells you about the sick pay (up to six weeks) and such.
So now let me do that math – say you make $30,000 – in Germany your insurance would be roughly $4500 – a little over half of that paid by you – that comes to about $2500 annually covering the employee and dependents (spouse and all children).
I made less then $30,000 here in Delaware, to insure myself and my son, my monthly pay came to roughly $500 – totaling annually $5000 – now my son has ADD – there is no co=-pay on medications for children in Germany – here the co-pay for his meds is around $20,00 a month – so add in another @240 annually.
I think you get my point.
I love living in the US – I just think some things could be better.
Thanks for commenting Suzanne. We’ll have to add your blog (which looks great BTW) to the blog roll.
Thanks Jason – appreciate it! I have a second blog at http://www.equalitydrive.com – but that’s geared towards gay and lesbian issues.
I just checked out your blog as well. Nice work.
And your point about Europe is well taken. My brother lived in Siena, Italy for six years and his wife is Italian. The European healthcare horror stories are grossly exaggerated. Funny, how Republicans cite them constantly while ignoring our own little shop of horror stories.
While in Canada this summer I had a discussion with a new acquaintance about their healthcare system. While he said it seemed to work well in terms of getting inexpensive medical treatment in a timely fashion, he had real concerns about the quality of the service. Apparently, medical professionals were migrating south to the USA in droves because they can make more money here than in Canada. This confirmed a conversation I had with a nurse at PGH in Salisbury a couple of years ago. She told me that she and six of her classmates came here for the same reason.
If alot of the problem is high premiums due to the low number of insured in the group… why not have a system, which is the same as it is now, but just have anyone who wants to sign up for it eligible.
Make Delaware one large group policy. Yes, we all pay our premiums and copays, but the group bears the burden, and it pays for itself. No taxpayer money.
Pandora asked:
The last time I needed to see a specialist; I can make appointments directly with an ophthalmologist (last time earlier this year) or my GI specialist (last time in 2004) whenever I need to do so. The same is true with the dentist, though most people wouldn’t think of that as seeing a specialist.
Dana,
First, dental and eye care are their own branches, branches people add (and pay for) to their health insurance policy.
Second, if you want to see a cardiologist, etc. you will need a referral from your primary physician.
Pandora: if I didn’t need a note from my primary care physician to see a GI specialist, it’s unlikely that my insurance provider would require one to see a cardiologist. I can imagine that the cardiologist;s office would wonder why I was making a cardio appointment without seeing a GP first; they’d probably figure I was self-diagnosing via WebMD.
Yes, it is uncommon to be able to see a specialist without a referral. So you have to wait to see your GP and then you have to wait to see the specialist.
Dana obviously has excellent insurance. He can see who he wants, when he wants, and all is paid for. This is not the norm in our country, and I’d be very curious as to what he pays every month.
I’ve already admitted that my insurance is pretty darn good, and yet, with every passing year, costs rise while services get cut. Are you really not experiencing any of this, Dana?
Just remember folks all those countries that have Universal Health care run by their Governments LIVE LONGER THAN US. Now tell me what is worth to each of you to be allowed more time in your life to spend with your grand Children.
And that stands for Cuba also
Unless you have some excellent insurance, referrals are generally a must. Which means, you often have to see your GP first, pay a $20 co-pay for a silly piece of paper or a phone call referring you to a specialist. Then, you see the specialist, whose co-pay is always higher. It’s a fucked up system we’ve got here.
Single-payer all the way, baby!
Suzanne from Germany talking about teeth reminded me of my own personal story of why our insurance system is fucked up.
My wife now has two teeth implants in the front of her mouth. During her teenage years she had fake teeth attached to braces, then in early 20s had a bridge. Eventually the doctors told her bridges are not a long term solution, they’ll keep breaking or having to be replaced, we recommend you get teeth implants.
This whole situation eventually led to us reading perhaps one of the most assinine things ever printed on an insurance claim form: “No coverage for congenitally missing teeth.”
That’s right, folks, it wasn’t that she was in an accident or practiced poor oral hygiene. She was missing two of her front teeth because she never had them to begin with! It’s a trait that shows up in her family approximately every other generation and she was one of the unlucky ones.
Gotta love when the insurance company’s attitude is “Oh, you were born without two of your front teeth and all your doctors say you should get tooth implants? Sucks for you, guess you should’ve had better genes.”
Needless to say, we now pay the equivalent of an extra car payment every month between dentist and periodontist bills thanks to our glorious insurance system. And for any repub douchebag out there who is just itching to say “But but that’s a cosmetic procedure, the insurance company shouldn’t have to pay” – I ask you, how would YOU feel if you had a job where you regularly work with the public and receive stares from people because you have missing teeth – teeth that were never there to begin with!
I never checked, but I wonder now if the insurance company would have paid for it had the teeth been knocked out in an accident rather than been congenitally missing. Perhaps I should have “accidentally” smacked her in the face with a baseball bat so we could’ve saved a couple grand.
TT, they live longer than us because their lifestyles are much different than ours. I don’t think it’s the healthcare.
TT: the health care bill put forth by Hilary was the single payer bill, and the republicans went ape! Single payer was put in place in Europe after WW2 when they were flat broke (kinda like where we are right now). They have had decades of preventative medicine.
Second europeans are truly a family value group of nations which is why they provide family leave when a new baby is born. A mother and father get 6wks off and the mother gets l year to nurture the child. Breastfeeding is a big healthy plus. They also get 6 wks vacation to provide time with their families.
Europe is not a consumer driven society like the US. They are more frugal with their money and they save. We have a lot to learn from them as we create a nation of change.
John Kowalko was just on Chan 28 a great supporter of single payer. He will do everything he can to push it. So will newly elected Earl Jacques. We already have 18 members in the house supporting it..Earl will be 19. So its up to us to get others to sign on, at the very least get the hearings we need. Hope everyone here will help. As Kowalko just stated “wind power” was supported by 94% of Delaware and still was about to go dead! It has to be discussed on the air and everywhere we can to make sure we get the issue addressed. Remember the State Chamber and the Public Policy Institute have 7 lobbyists to everyone of us.
Another Mike. There is a big difference in England and the rest of Europe. In Europe all the nurses/doctors are paid salaries directly from the government. The rest of Europe is the system we propose…the doctors remain in private practice and you pick and choose all your health care providers.
In England there is a backlog for care because their system is truly government run. That is not the system we propose.
Meant to say, in “England” the nurses and doctors are paid for directly by the government. Not so in the rest of Europe!
Senator Kennedy is back in the Senate and will work on health. Physicans for National Health Care and other national health care groups are urging all progressives and labor groups to contact your legislator and support HR 676! We don’t need a new bill as the republicans are pushing. They want to tweak the original Richard Nixon plan for profit health care system.
Single payer would help fix the auto industry but unless there is enough support nationwide we will never get real universal care!
Or you can continue to purchase on your own, but companies are opting out. When you republicans talking about bailing out the auto industry notice they want them to declare bankruptcy. Under bankruptcy they will lay everyone off and rehire without health care or pensions. Can’t afford to buy your own health care…too bad. do with out, its a dog eat dog world.
Of course here in Delaware we should be working on Markell but in reality he is also listening to the State Chamber and Delaware Policy Insitute…so good luck with that.