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Insurance: A Patient's Perspective



Hi.  my name is Emily Dalton, and I am a local pediatrician.  I have had the unfortunate experience of dealing with the health insurance system from 3 different perspectives:   that of a patient who uses an insurance plan, that of a small business owner who purchases insurance for a group of employees, and that of a physician who contracts and gets paid by various insurance companies.  I am here to tell you that the system is broken.  What is going on today in medicine is so ineffective that we need to reinvent our nation’s healthcare system from the ground up.
As a patient, I am tricked by the insurance plan I bought.  Even though the plan is called “HSA 2000”, the deductible for my family is actually $4000.  When we bought the plan we were told the insurance would cover 80% of the charges after the deductible, but after signing up that percentage was changed to 70%.   Despite the deception, I am stuck with this costly plan for the rest of the year and I have no options to change it.   When I call my insurance company to address problems, I must make sure that I have several hours of free time, so that I can stay on hold long enough to get through to a low level representative who has little power to do anything.  The disclaimer  “Description of covered benefits is not a guarantee of payment” makes me fearful and insecure.  I am at the mercy of large, for -profit corporation that is beholden to shareholders and run by greedy corporate executives who do not care about me.  
Having insurance means little anymore.  Deductibles are high, share of costs are high, and many benefits are simply not covered.  Deny, deny, deny!  The company has so many devious ways of denying payment that even a sophisticated health care “consumer” can be taken by surprise.  The reason for denial could be the type of treatment,  lack of a contract with a specific provider, or that your medication is non-generic or not on formulary.   Before purchasing my policy I made sure the medication I needed was listed on the formulary I found on the company’s website.  After the cost of the medicine was denied, I was told that the formulary I viewed was not the formulary associated with my plan.  When I asked to see the formulary for my plan I was told it was not available.  
The fourth time my insurance denied a claim, I realized what was going on.  In the past insurances could kick you off for getting sick or refuse to accept you for having a pre-existing condition, but now they are legally obliged to accept all comers.  However, they have found a new way to shed their undesirable patients:  balk, deny, hassle and ignore you until you willingly transfer your diseases to another company.  If they deny payment long enough, your doctor may send the bill to collections and you can end up being hassled by a collection agency as well.   Ah,  insurance is wonderful---JUST DON’T GET SICK!
Every time the company refuses to pay for a procedure, consult, or medication, the company gets to keep the money!  Every time the company “forgets” to pay a claim, the company gets to keep the money!  Each time the company raises premiums, the company gets to keep the money!  The worse they behave, the more money they make.   Are we crazy to tolerate such a system?
The Affordable Care Act, despite the best of intentions, has fortified a monster.  By mandating that everyone purchase insurance, the industry feels emboldened to take advantage of patients and healthcare providers.   Exponentially larger and more powerful than the agencies assigned to oversee it, the insurance industry finds ways to circumvent and resist restrictions.  This leech has gotten firmly latched on to the lifeblood of American medicine,  and is sucking out money and energy from all angles.    Like a cancer, is has created harmful malfunctioning growths that waste our precious health care dollars.
I wish “ObamaCare” was what conservatives imagine it to be and hate--a comprehensive, MediCare-like, government-run system--and I wish I could sign up for it.

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