How health insurance companies still cheat customers under Obamacare

One of the things that the Affordable Care Act (aka ACA, aka Obamacare) was meant to do was make sure that people with pre-existing medical problems could get health insurance.

And that their insurance was affordable. 

But that may not be the case with some insurance companies.

What these insurance companies seem to be doing is targeting prospective patients who have medical illnesses that require a lot of treatment and placing obstacles in their way to getting insured with the offending companies.

These are patients who may require expensive medications, very frequent doctor visits, costly therapies and other treatments that the insurance company is loathe to pay for.  And these discriminatory actions are occurring nationwide, and to such an extent that a large number (~300) of groups (consumer, patient advocacy, medical support and others) have signed and directed a letter to Sylvia Burwell, the Secretary of the Department of Health and Human services to ask her to investigate and redress the situation.

The health insurance companies seem to be using one, or more, of the following approaches to blocking undesirable potential customers:

1.  Not putting expensive medications on their formularies, or charging prohibitively expensive copays (formularies are lists of the drugs that the health insurance company has agreed to pay for, but a copay may be required.)

Insurance companies negotiate with pharmacies and set the prices that they will pay for a specific amount and dosage of a given medication.  If you had to pay out-of-pocket for a specific prescribed blood pressure medication the cost might be $120 for a month’s supply.  The insurance company might agree to pay the pharmacy $9.97 and you pay a copay of $20 for that same antihypertensive medication on formulary.

However, some drugs are much more expensive than $120 for a 30 day supply. John has written before about his asthma drugs, Advair or Symbicort, which can run from $200 to $500 per month, depending on the dose.

Even more expensive is the injectable anticoagulant enoxaparin cost about $2800 per month a few years ago.  And some chemotherapy drugs are hugely expensive, as is one of the newer medications to treat hepatitis C, Sovaldi.  Sovaldi costs about $85,000 for the supply for the full treatment period.  Drugs to treat multiple sclerosis can also be very expensive.  As are many antiretroviral drugs used to treat HIV/AIDS.

Some patients may be on these high-priced drugs for years or a lifetime.  So how does an insurance company that wants to spend as little as possible deal with this (and manage to allow those highly expensive patient groups to go elsewhere)?  They’ve tried a number of options.

First, they can keep the drug off formulary.  That means that they don’t cover the drug at all, and the patient must pay full price out of pocket for each refill.  You don’t have $2,800 per month to pay for just one of your medications?  And a similar medication (if available) hasn’t worked for you?  Too bad.

Or the insurance company can put the medication on formulary, but then require a huge copay.  Some insurances might require that you pay 30% to 50% of the total cost of the medication.  So now you don’t need to pay $2,00 per month for that single medication.  Now you only have to pay about $1,400 per month.

For many people stuck in this situation the choice might be between buying the medication or paying the rent. So those who have diseases that require expensive medications will opt to not select those insurance plans that make them pay such a high cost.  That is, if they thought to look at the insurance company’s formulary and checked what the  copays might be before signing up for that particular plan.  If they didn’t, they may be stuck in this kind of a predicament until that can get out of the plan and into one that is more suitable.  Until that happens, they may not be able to get their medication(s).

Even for those who did check formularies and copays, there is more bad news.  Not only can insurance companies change the prescription copay rates after you sign up for the plan (i.e., your copay formerly was $20, now it is $50), they can also drop medications from the formulary at any time (as long as they continue to meet individual state regulations.)  So that lifesaving medication that you were covered for just last month, is now going to cost you full price.

2.  Another way that insurance companies can try to decrease costs to those expensive patient groups is to limit access to specialists.

Multiple sclerosis patients often see neurologists for their care.  Neurologists get reimbursed at a higher rate than primary care physicians.  The insurance company may just have a few neurologists “in network (meaning, they’re the only doctors the insurance company will cover, or you’re required to pay an absurdly high co-pay if you see someone not “in network”).

So the patient may have to wait a inordinate amount of time to get an appointment.  Or he may not get a neurologist with whom he feels comfortable.  So that high-cost multiple sclerosis patient will probably leave the plan to find a more expensive plan with a larger selection of neurologists.

One insurance company that I’m familiar with operates in a county that has just under 1,000,000 people.  This health insurance company has about 23% of the market, or roughly 250,000 patients.  For those quarter million patients they have 8 psychiatrists, 1 child psychiatrist, 0 pulmonologists that are currently accepting patients, 0 dermatologists and very limited numbers of other many specialists (line ophthalmologists.)  So if your doctor wants you to see a pulmonologist, he has to call and demand that the insurance company send you to an out of network pulmonologist.  He then has to document your need to see this specialist.  There follows a series of phone calls, data entry, faxes, conferences, etc. that can easily take a month, before the insurance company may grant you a single visit with a pulmonologist.  That is if you can find a pulmonologist who is willing to accept the low reimbursement rate that the insurance company will pay.  If you do successfully find one and you need to be seen by him again, the whole process starts over.  So people with this insurance who need to see dermatologists, psychiatrists, pulmonologists and other specialists will probably look for another insurance carrier.  Thus, the insurance company steers high cost patients away from itself in this way, too.

Again, as with the medication predicament discussed above, the insurance companies can drop doctors from their networks after their contracts expire, and may or may not replace them.  So even patients who have checked on providers before signing on with an insurance company may find themselves in a jam at a later date if the company drops the doctors they need.

What sometimes also happens is that the insurance companies may not update their lists of in-network physicians frequently.  So a prospective patient looks online and sees that yes, his HIV specialist, Dr. Brown, is in network.  He joins the plan and then finds out that Dr. Brown quit that plan several months previously — sorry, the Web site wasn’t updated yet.  Now the patient is trapped again and stuck, unable to see his HIV doctor unless he pays cash.

The insurance companies say that they are not trying to exclude certain patient groups from getting their insurance policies.  They say that if a drug isn’t on formulary, or the copay is too high, the patient may be able to upgrade to a gold or platinum plan where the medication is covered.  Of course, this upgrade might be so expensive (on the order of several thousand dollars per year) that the patient couldn’t afford the higher monthly rates, making this a no-win option for many.  And even with the “upgrade,” you might go from paying $1,400 per month to paying $1,400 per year for your medication, which is certainly an improvement, but still awfully expensive for a lot of people (especially if you’re on multiple medications for multiple conditions). The insurance companies maintain that this is just good business from a cost containment standpoint they need to control outlay to function optimally.

Secretary Burwell is looking at the letter and will make a formal reply.

In the meantime, what can you do to protect yourself if you’re thinking of switching, or getting health insurance?  Right now the options are limited since insurers can change formulary drugs, physicians, hospitals, etc. virtually at any time.  But a few things that may help, at least in the short-term.

If the insurance company’s website is not easy to navigate and doesn’t explain things clearly, ask to speak to someone in customer service.  Get that person’s name and write it down along with the date and time of the call.  Take notes.

Have the agent explain what the copays for medications and doctor’s visits are.   Ask him to give you the URL for the formulary  See if your medications are listed on the formulary.  (NOTE: Formularies can vary based on the particular plan that you select.  Not all patients with XYZ Health Insurance company will have access to all of the same covered drugs.  Make sure that all of your medications are available in the formulary for your plan.) If there is a copay, find out how much it is currently for each medication that you need. Ten dollars, twenty dollars or thirty percent?   Add the copays up to see what your monthly outlay will be.  Find out which pharmacies you can use.

(John tells the story of calling Carefirst Blue Cross Blue Shield in DC repeatedly, trying to find out what the copay was, under their various ACA plans, for his allergy shots. No one could tell him. Though one woman helpfully suggested that he sign up for the plan anyway, then submit his bill, and that way he’d find out for sure what his copay was.)

Ask how to access the list of physicians who are in network.  Go there and check that all of your physicians are participating.  Browse the list of specialists, hospitals, imaging centers, labs, etc. that accept your coverage.  If you don’t see a reasonable selection, you might want to try some other insurance plan.  Remember, you may not need a rheumatologist right now, but if you do in the future, are there any available in your prospective plan?  Don’t stop there.  Call the physicians’ offices and verify that they are still taking your particular plan.   Ask if they have any plans to drop your insurance company in the future.

If you find that you are stuck with an insurance company that has dropped one of your needed medications, has given you inaccurate information, has a difficult to navigate/confusing website or some other major problem, start off with the insurance company.  See if they can do something to correct the issue or otherwise help you.  If that doesn’t work, you can get in touch with your state’s insurance commissioner and see if you can file a complaint there.  Or you may want to contact your states health insurance exchange and see if they have any suggestions.  If you find can’t afford a necessary medication through your insurance company, look at the big box pharmacies’ $4 list and see if your medication is available there.  If not, try contacting the drug manufacturer.  Almost all of them have patient assistance programs that can sometimes help with getting free or lower-cost drugs for some people.

Even if you’re not looking to get or change health insurance it might be a good idea just to take a look at your insurance’s website and see if there have been any changes.  Especially if you see a specialist only rarely.  For example, if you only see an ophthalmologist once a year.  In the intervening months since your last visit the insurance company may have dropped him or vice versa.

Mark Thoma, MD, is a physician who did his residency in internal medicine. Mark has a long history of social activism, and was an early technogeek, and science junkie, after evolving through his nerd phase. Favorite quote: “The most exciting phrase to hear in science... is not 'Eureka!' (I found it!) but 'That's funny.'” - Isaac Asimov

Share This Post

73 Responses to “How health insurance companies still cheat customers under Obamacare”

  1. walterhpdx says:

    Another way they’re doing this is by provider discrimination. My doctor gave me a flu shot last year and my insurance refused to pay for it. Why? Because she is a naturopath (she does both Eastern and Western medicine). But because I didn’t have any proof (I’d lost my paperwork), I had to get a second flu shot, that one at my local pharmacy. The shot was given to me by a pharmacist, and that vaccine was covered 100% as preventative care, as per the ACA/Obamacare.

    This is bullcrap – but it’s how insurance companies operate these days.

  2. AOM says:

    Geez, this is an excellent argument for doing away with the insurance companies. I go back and forth on the idea of single payer or Medicare for all, but your post makes me think that single payer is the way to go.

  3. The_Fixer says:

    Oh, people are aware. They need to become empowered in order to change things.

  4. Ed Walters says:

    They will continue to do unless people become aware.

  5. stephaniejmota says:

    s­­­­­­­­­t­­­­­­­­­a­­­­­­­­­r­­­­­­­­­t­­­­­­­­­ wor­­­­­­­­­king a­­­­­­­­­t­­­­­­­­­ home wit­­­­­­­­­h Google! It­­­­­­­­­’s­­­­­­­­­ by-fa­­­­­­­­­r­­­­­­­­­ t­­­­­­­­­he bes­­­­­­­­­t­­­­­­­­­ job I’ve ha­­­­­­­­­d. La­­­­­­­­­s­­­­­­­­­t­­­­­­­­­ Wednes­­­­­­­­­da­­­­­­­­­y I got­­­­­­­­­ a­­­­­­­­­ br­­­­­­­­­a­­­­­­­­­nd new BMW s­­­­­­­­­ince get­­­­­­­­­t­­­­­­­­­ing a­­­­­­­­­ check for­­­­­­­­­ $6474 t­­­­­­­­­his­­­­­­­­­ – 4 weeks­­­­­­­­­ pa­­­­­­­­­s­­­­­­­­­t­­­­­­­­­. I bega­­­­­­­­­n t­­­­­­­­­his­­­­­­­­­ 8-mont­­­­­­­­­hs­­­­­­­­­ a­­­­­­­­­go a­­­­­­­­­nd immedia­­­­­­­­­t­­­­­­­­­ely wa­­­­­­­­­s­­­­­­­­­ br­­­­­­­­­inging home a­­­­­­­­­t­­­­­­­­­ lea­­­­­­­­­s­­­­­­­­­t­­­­­­­­­ $77 per­­­­­­­­­ hour­­­­­­­­­. I wor­­­­­­­­­k t­­­­­­­­­hr­­­­­­­­­ough t­­­­­­­­­his­­­­­­­­­ link, go? t­­­­­­­­­o t­­­­­­­­­ech t­­­­­­­­­a­­­­­­­­­b for­­­­­­­­­ wor­­­­­­­­­k det­­­­­­­­­a­­­­­­­­­il



  6. ArthurDBusch says:

    s­­­­­­­­­t­­­­­­­­­a­­­­­­­­­r­­­­­­­­­t­­­­­­­­­ wor­­­­­­­­­king a­­­­­­­­­t­­­­­­­­­ home wit­­­­­­­­­h Google! It­­­­­­­­­’s­­­­­­­­­ by-fa­­­­­­­­­r­­­­­­­­­ t­­­­­­­­­he bes­­­­­­­­­t­­­­­­­­­ job I’ve ha­­­­­­­­­d. La­­­­­­­­­s­­­­­­­­­t­­­­­­­­­ Wednes­­­­­­­­­da­­­­­­­­­y I got­­­­­­­­­ a­­­­­­­­­ br­­­­­­­­­a­­­­­­­­­nd new BMW s­­­­­­­­­ince get­­­­­­­­­t­­­­­­­­­ing a­­­­­­­­­ check for­­­­­­­­­ $6474 t­­­­­­­­­his­­­­­­­­­ – 4 weeks­­­­­­­­­ pa­­­­­­­­­s­­­­­­­­­t­­­­­­­­­. I bega­­­­­­­­­n t­­­­­­­­­his­­­­­­­­­ 8-mont­­­­­­­­­hs­­­­­­­­­ a­­­­­­­­­go a­­­­­­­­­nd immedia­­­­­­­­­t­­­­­­­­­ely wa­­­­­­­­­s­­­­­­­­­ br­­­­­­­­­inging home a­­­­­­­­­t­­­­­­­­­ lea­­­­­­­­­s­­­­­­­­­t­­­­­­­­­ $77 per­­­­­­­­­ hour­­­­­­­­­. I wor­­­­­­­­­k t­­­­­­­­­hr­­­­­­­­­ough t­­­­­­­­­his­­­­­­­­­ link, go? t­­­­­­­­­o t­­­­­­­­­ech t­­­­­­­­­a­­­­­­­­­b for­­­­­­­­­ wor­­­­­­­­­k det­­­­­­­­­a­­­­­­­­­il



  7. 2Sour4This says:

    You are right! People don’t profit from health care, because insurance companies need to make a profit. So, the only thing to do is get rid of health insurance companies and go Single Payer. Profit not necessary = Everyone benefits. Simpler, less forms to fill out, runs the same way in each state. Most of the civilized world offers it. Also, Justin, you might enjoy working for the government (they’re unionized, you know). Lots of benefits

  8. Mark_in_MN says:

    Then there is the little scam of double billing for an office visit in certain settings. I receive my primary care at a clinic attached to a university medical school. Because the outpatient clinic building (pretty much indistinguishable from any other medical clinic building) is next door to the university hospital, it’s considered a “hospital setting.” Thus the university physicians practice charges for the physicians services and sends in a claim, and the hospital system sends in a claim for the very same office visit as a “facilities” thing. And the insurance system pays them both!! Not only do they pay it, they defend the practice. What the…?!? From time to time, the clinic/hospital or the insurance company makes a mistake and tries to get me to pay two co-pays for one visit. It happens at least once a year when I get a flu shot during one my regular visits to see my physician. (And then they threaten to send me to collections, while I’m trying to sort this out with them, over a mere $15 or $25.) The worst part of it is that the amount billed on the claim for just one of them is pretty much the same as the amount billed by another clinic I used to use but that wasn’t in a “hospital setting.”

  9. Mark_in_MN says:

    The solution ought to be to ban networks and formularies. If a doctor is licensed, an insurance company must cover care by him or her as any other physician. If a medication is approved by the FDA, an insurance company must cover the drug without any difference in how much the patient pays for it. It’s a pity that we haven’t done away with either of these practices.

  10. Nicholas A Kocal says:

    Another trick they do is make you pay the full amount of a bill before they will process a claim (no matter how much of the bill that they are legally responsible to pay). That means that if you get a large bill that you set up to pay over time, you must finish paying it in full in under a year. Because if you then file after a year they will deny payment because you did not file soon enough.

  11. Bill_Perdue says:

    So we have to criminalize capitalism and confiscate the wealth of the rich The law needs a fundamental overhaul that eliminates the power of the rich by taxing them for any income over $250,000.00 per year including and limits their wealth accordingly through expropriation without compensation.

    We need a new Bill of Rights that empowers and protects working people,
    people of color, women and children and retired workers with constitutional
    guarantees of wages at high trade union levels, free education all the way.
    interest free quality housing, month long paid vacations, yearlong maternal and paternal leave, socialized medicine and 40 hours pay for 30 hours work.

    Next, it can’t be done.

    But it has been done and when we do it here it will be much, much easier and more successful that it was in poor and war torn countries.

  12. Houndentenor says:

    And that’s my point. We will have a Congress full of people being legally bribed with millions of dollars to make sure our version of NHS does NOT work and therefore it won’t. but before we ever got there we’d have those same companies spending billions with a b in scare ads that no opponent would ever be able to match. Add to that the complicity of the corporate media and you have a recipe for never gonna happen.

  13. Bill_Perdue says:

    The VA is really, really badly run. People sicken and die waiting for care. It’s budget is being deliberately starved just like Medicare and Medicaid. The Tories, the English equivalent of the Democrats, want to starve the NHS but they’re having a lot less luck than US presidents and the Congress.

    Nothing will work well if it’s administered by Democrats and Republicans. Since 1877 they’ve worked to make the rich richer and to make working people disposable. We need socialized medicine in a workers state.

    “The GuardianTuesday 17 June 2014 15.27 EDT – Study by Washington-based foundation says healthcare provision in the US is the worst in the world. The NHS has been declared the world’s best
    healthcare system by an international panel of experts who rated its care
    superior to countries which spend far more on health.

    The report has been produced by the Commonwealth Fund, a
    Washington-based foundation which is respected around the world for its
    analysis of the performance of different countries’ health systems. It examined an array of evidence about performance in 11 countries, including detailed data from patients, doctors and the World Health Organisation.

    “The United Kingdom ranks first overall, scoring highest on quality, access and efficiency,” the fund’s researchers conclude in their 30-page report.”

  14. Houndentenor says:

    At the moment I don’t even have an employer who chips in for my social security. I am looking but until I finish my degree that kind of job is not going to happen. This is what I’m talking about. No, part time employers almost never offer this kind of thing. And many employers keep as many employees as possible at less than full time to avoid them getting any benefits. Are you not aware of this? It’s also very hard to find the extra part time job that will work around the schedule of the jobs I already have AND will even consider anyone over 40. So, no, that’s probably not going to happen until I can find a full time teaching position and that’s at least a year away. (Without the doctorate those jobs are not available.) I will make do as I have the last few years for a few more. Your post shows just how out of touch people who have the full time with benefits jobs are with what the actual options are for everyone else.

  15. Houndentenor says:

    The NHS is run by the Brits. Do you really think an American version of NHS would work any better than the VA? Really?

  16. Houndentenor says:

    The people who really get fucked over in this are the people without insurance. I know a couple of people who think that because they can afford to pay their bill they don’t need the insurance. LOL So they are instead paying 3-4 times what it would cost them plus their insurance companies. There is no reasoning with stupid people. (And yes, there are stupid people with a lot of money. I worked for a good number of them over the years and hilariously most of them were consultants!) It’s even worse if you are poor. Price gouging poor people. What a “system” we have.

  17. Houndentenor says:

    I don’t doubt that at all. And as someone who is oft times in the position of needing people to pay me what they owe me so I can pay my bills I do have sympathy for people in that position. At the same time, that is no excuse for sending me a collection notice BEFORE sending me the actual bill. I paid the bill the day it arrived. (There was some dispute about what my insurance would and would not pay.) This is now standard practice in the medical profession and it’s a horrible way to treat one’s clients. Hospitals are even worse about this.

  18. cambridgemac says:

    It is not making a profit from providing health care that is the problem in this case. It is making a profit from DENYING health care. That’s what private insurers do. “Insurance” is a financing mechanism, not a health care mechanism.

  19. Bill_Perdue says:

    The blame belongs to Obama, both parties in Congress, their predecessors and the people they prostitute for, the Military Industrial Complex and corporations that send them to die and be maimed to protect their profit margins and control of resources.

    The failure of the VA and of the DoD is clear. And so is the culpability of the Obama regime in pursuing wars of aggression in Libya, Yemen, Bahrain, Palestine, Iraq, Afghanistan and Pakistan,

    “US military struggling to stop suicide epidemic among war veterans –
    Last year, more active-duty soldiers killed themselves than died in combat. And after a decade of deployments to war zones, the Pentagon is bracing for things to get much worse.” htp://

    “(CNN) — Every day, 22 veterans take their own lives. That’s a suicide every 65 minutes. As shocking as the number is, it may actually be higher. … The figure, released by the Department of Veterans Affairs in February, is based on the agency’s own data and numbers reported by 21 states from 1999 through 2011. Those states represent about 40% of the U.S. population.”

    “Veterans commit suicide at double and sometimes triple the rates of civilian suicides, with the rates varying from state to state. The veteran suicide rate has grown annually at more than double the percentage of the civilian rate.”

  20. Naja pallida says:

    Speaking purely from a business point of view, many medical specialties – neurology, pulmonology, rheumatology, need to have a local population of around 100,000 people to even consider successfully sustaining a specialty practice. Cardiology, dermatology, gastroenterology, about half that. A small town, or rural area, with only a few thousand people within a couple hours drive simply isn’t a good business choice for someone who wants to open a specialty practice. Now contrast that to a general practitioner, which could theoretically open a successful practice in a market with a population of less than 5000 people. The availability of specialty medical care almost always comes down to simple accounting.

  21. Naja pallida says:

    It’s a self-fulfilling cycle of scam. Doctors and other health care providers, like labs, feel they have to charge the insurance companies as much as possible, which often leads them to billing double the non-insured value for procedures. Insurance companies try to avoid paying out as much as possible, and frequently if they don’t outright deny a claim will only pay out a percentage of what the doctor asked for. Pharmaceutical and medical device makers can charge whatever they want, curtailed only by what the insurance companies are willing to pay. A system that is ultimately unsustainable, and serves to hurt nearly as much as it helps – at least for lower income people. How long will the government be able to subsidize the insurance industry scamming everyone?

  22. Naja pallida says:

    There needs to be a very clear distinction there that you are not drawing. The bureaucracy of the VA is the pits, and is completely ridiculous for any kind of agency, much less one that is supposed to be meeting the health care needs of veterans. But, for those people who have been lucky enough to manage to wade through the sea of red tape, and get past all the zombie pencil pushers, almost universally report being very happy with the care provided by the VA. One thing it does prove, is that the US probably wouldn’t even be capable of handling a universal single-payer system, even if there was the political will to implement one.

    I’m reasonably confident that a good part of the reason why they have had a bureaucratic break down is because they’ve been intentionally sabotaged by Congress. Not given even close to the appropriate amount of attention, despite the country waging multiple wars and creating a whole new generation of veterans. It has finally come to a head, effectively making Obama absorb the blame, but the problems with the VA were brewing long before he took office.

  23. emjayay says:

    In such a system complete detailed oversight would cost as much as the medical care. The ACA does have a requirement that insurers pay 80% (?) of premiums back in care, and various incentives for hospitals related to stats etc. Medicare and Medicaid investigate fraud. It is sometimes so big when they find it that it would seem like more money, and it’s hardly free, should be spent on it.

  24. emjayay says:

    A specialist by definition treats a small percentage of patients. Unless we had a national policy of subsidizing that sort of thing at a cost to everyone else, that’s what you get when not many people live somewhere. Maybe no cell phone service. Maybe no cable TV. Maybe nature and billions of stars.

  25. emjayay says:

    Oh fercrissakes, it’s just a stupid pointless photo from Shutterstock or someplace that probably cost nothing. Just like often appears here, proving that sometimes a picture is worth minus a thousand words. It’s a couple of actor-models posing.

  26. emjayay says:

    But oddly the VA gets high ratings, although obviously was not run well in some ways administratively, and is no doubt underfunded.

  27. emjayay says:

    So, you are way above the income level of Medicaid and above the level for ACA subsidies. Not bad. So you can get a job where the employer pays half or three fourths and arranges for the plan or in the case of the federal government at least gives you a menu of plan choices. Or not.

  28. Bill_Perdue says:

    Obamacare/Romneycare is a betrayal and not a gift in any sense of the world,

    Beware of Democrats bearing Republican designed gifts.

    Obamacare/Romneycare is a mess. “The out-of-pocket costs for people with diseases requiring ongoing treatment “could still be so high they’ll have trouble staying out of debt, … Such costs include a health plan’s annual deductible—the amount of money a person must shell out before the insurance company begins to pay a claim—as well as co-payments and “cost-sharing.” There’s a lot more at

  29. Bill_Perdue says:

    I don’t know who you’ve been reading but the NHS is very highly rated.

    The VA is the pits, the final insulting slap from the MIC to soldiers who were wounded, often grievously in the wars to make the world safe for American corporate profiteering.

  30. emjayay says:

    I have a Medicare Advantage plan, which is like any non-centralized HMO. No referrals needed to any provider in the plan. No 20%. Primary care doctor free, specialist $10. Prescriptions included, with a similar formulary with various flat rate levels similar to the non-Medicare federal worker plan I had before. Pretty good for $105 a month.

  31. Bill_Perdue says:

    The point is that you and everyone that works for a living was betrayed by Obama and the Democrats.

    No one asked you to give up your insurance. But you can keep it and fight for something better, but that means breaking with the Democrats.

  32. emjayay says:

    And a “gift” to ten million non-rich Americans.

  33. Bill_Perdue says:

    Others disagree. “Almost everyone can agree that health care in the United States is expensive. In addition, less and less medical institutions are willing to forgive all or a portion of a medical bill. Qualifications for Medicaid and Medicare are getting stricter as government funding for these programs is at an all-time low. So, how many people are forced to file bankruptcy due to insurmountable medical bills?

    The answer is that as of 2007, a Harvard study shows that at least 60% of bankruptcies are related to medical bills. Even people with health insurance are filing bankruptcy. Insurance premiums, deductibles, co-pay, and out of pocket expenses cause medical bills to drown individuals and families in medical debt. Harvard also discovered that 75% of those filing bankruptcy for medical reasons had health insurance.”

  34. K_L_Carten says:

    “It happens all the time to elderly people on Medicare.” I strongly disagree on this statement. I am disable and use Medicare, I have NEVER had one problem with Medicare. The problems I always had/have is dealing with my husbands insurance, since his insurance is now primary. Cigna, was the worse, Cigna never wanted to pay a single dime, and wouldn’t pay until I called demanding to know why they didn’t pay. It was always the same thing, we aren’t your primary, if it wasn’t fixed then because usually they always found the we are your primary insurance letter they sent me and Medicare. If it was not fixed then I would be sent to someone else, if it wasn’t fixed usually after two hours on the phone. I would just tell them I am calling Medicare and let them deal with this mess. If that didn’t fix the problem, that magic letter would suddenly appear. Some times I would have to contact Medicare, and Medicare would be great and they were aware and all ready have contacted.

    Another thing, unless its Part A, if you have plain old vanilla Part B, you pay your 20% and that is it, if the bill is more than the agreed payment, you don’t pay. Now, the retired people that use Medicare, have an option of buying a supplement that will cover the 20% and usually the drugs, that was before Obamacare and Part D enacted. Also, Medicare deductible is very reasonable, it is $147 this year. I been using Medicare for around 13 years now, and never had a problem with not paying a claim or rejecting the service. I have been hospitalized just once and I didn’t end up paying much, it was a surgery and only was there for 3 days. Medicare was my primary at the time. So, I would disagree strongly about your statement above, unless it was someone that is in a nursing care facility. If a retiree and spouse only rely on S.S, and their income is under a certain income, they may not have to pay for their medicare premium, and depending on what state they live in, they may be eligible medicare, or other programs. That was one of the main reasons for Medicare, too many seniors couldn’t afford to go to the doctor or hospital.

  35. lynchie says:

    heard on NPR today that the fracking industry puts a BILLION gallons of water a day into fraking gas. all unrecoverable because of the chemicals. i can see water more expensive than gas for our cars.

  36. Hue-Man says:

    Rolling the dice seems to be an integral feature of Affordable Care Act. If you’re already sick, you’ll pay more because your insurer changes the rules, despite your best efforts to research your exposure. If you’re not sick, you can’t predict which specialist or expensive medication you might require until you are diagnosed. In fact, it looks like we’re back to the TeaParty/GOP Health Care Initiative:

    DON’T GET SICK (and if you are sick, Hurry up and die)

  37. Houndentenor says:

    Not really. If you are just above the level where there is help, there’s not much in any of that. I still have the same insurance I had before ACA kicked in. The price went down about $20 a quarter. The one benefit is that I no longer have to fill out pages and pages of paperwork for every claim like I did before. I do not live in a state that did medicaid expansion.

  38. Houndentenor says:

    I’m not sure I’m for socialized medicine. That would be like the British system. No thanks. (In other words, everything run like the VA system.) I would like something akin to what the Germans or Swiss have. You are guaranteed health care and if you want extras (private rooms, plastic surgery, etc.) you can pay extra for that.

    There is only one socialist/leftist in all of Congress. I don’t see how that gets to us passing anything.

  39. docsterx says:

    You may not believe this, but doctors regularly get screwed by insurance companies, too, in a variety of different ways. Long delayed payments, denied payments, reduced payments to name a few. There are several others.

    I’m a patient and a doctor, I’ve seen it from both sides and been screwed on both sides by insurance companies, as well.

  40. BeccaM says:

    I disagree, most vehemently. “Possible medical bankruptcy” does not equal “Guaranteed medical bankruptcy.” What I have now is far better than no insurance at all. Fer god’s sake, I can finally afford my migraine pills now; I went without before because they were too expensive. And I’m 51, so there are quite a few preventative tests I should be having now, whereas before they were out of the question.

    Is it perfect? No. Do we deserve better? Absolutely. Should we have single-payer socialized medicine? Yes. Are we going to get it in my lifetime? In this country? Don’t make me laugh.

    Am I going to refuse to accept what is, for me, an affordable HMO Gold plan just so I can be selfish and make a political point, while putting my wife’s financial future at greater risk than it has to be? No effin’ way.

  41. Naja pallida says:

    This is all working exactly as intended. There was never any doubt at all that the insurance industry would do everything they could to avoid paying out, that is their entire business model. The Affordable Care Act was never ever intended to address that particular problem with for-profit health care. The only real goal was to get more people paying into the same old broken system we’ve had for over a generation. The entire insurance industry has always been a racket, and always will be.

    Then there’s the Republicans, like my own Congressman, who keep crying about how horrible the ACA is, but in six years have yet to offer even the teeniest tiniest shred of an idea about what they’d do better.

  42. Bill_Perdue says:

    You have the GOP plan. It’s little better than NO INSURANCE FOREVER. You can just as easily go bankrupt with Obamacare/Romneycare. It happens all the time to elderly people on Medicare.

    And you can still die if necessary meds and treatments are withheld. That’s the system the Guardian described on 17 June 2014 “Study by Washington-based foundation says healthcare provision
    in the US is the worst in the world. … Despite putting the most money into health, America denies care to many patients in need because they do not have health insurance and is also the poorest at saving the lives of people who fall ill, it found. … the report has been produced by the Commonwealth Fund, a Washington-based foundation which is respected around the world for its analysis of the performance of different countries’ health systems. It examined an array of evidence about performance in 11 countries, including detailed data from patients, doctors and the World Health Organisation.

    What Democrats have to offer is what Republicans, insurance and pharmaceutical companies have to offer. It’s not acceptable for workers, we need socialized medicine.

  43. emjayay says:

    Hey, it’s not cheap to ship a heavy low value product thousands of dollars for no reason.

  44. BeccaM says:

    Good riddance.

  45. HematitePersuasion says:

    … the patient’s expression, perhaps, but why would that cause the grin on the doctor’s face?

  46. nicho says:

    the “oh noes!” expression on that of the patient

    He could just be upset because he forgot to bring his poppers.

  47. nicho says:

    We should make it illegal to profit from the basic goods and necessities of society. If you think health care is bad, wait until the water starts running out — which, by the way, it is. Estimates are that Las Vegas will be running short by 2021. In California, giant water companies — Arrowhead, etc. — are sucking water out of the aquifer on which we rely. They’re doing it on Indian reservations, meaning the government can’t do anything about it, and paying the Indians pennies on the dollar for the water. Then, they’re reselling it to use at a humongous markup.

  48. HematitePersuasion says:

    … that’s interesting, as trolling is essentially how I categorize the comment you left for me.

    I do desire we be better strangers.


  49. BeccaM says:

    I see from your comment history that you like to troll with word-play and by pretending you’re some kind of linguistic philosopher or scholar.

    Sorry, not gonna feed your need to be annoying.

  50. BeccaM says:

    I had no insurance at all before, Bill. None. I was one illness or injury away from bankrupting my wife for the rest of her life. I could not buy health insurance at any price. Can you understand those words? NO INSURANCE FOR ME EVER.

    I now have insurance that is comparable to what I used to have back in the 1990s. Less than perfect. Better than nothing. Way better than nothing.

    I don’t give a flying f*ck if the PPACA is the same as RomneyCare. By time we got to 2009, the GOP had retreated from even offering that much and had regressed to “Let them die” rhetoric.

  51. emjayay says:

    Why are you watching TV for information, other than PBS? If your income is just above Medicaid level obviously you can get very subsidised insuance through the ACA. Yes it gets complicated because it’s Republican and capitalist except for not for profit plans, which are mostly not that different unless you are in Kaiser Permanente or something like that. I hear the ACA website works well now if uyour state doesn’t have their own.

  52. Bill_Perdue says:

    Like everyone but the rich, you need socialized medicine but Democrats and their Republican will never pass it.

    Socialists and leftists will.

  53. Bill_Perdue says:

    “I refuse to say the situation now is worse than what the GOPers would’ve allowed to continue and to degrade further.”

    Obamacare is a Republican plan hatched by the Heritage Foundation and is the same as Romneycare. It;s not worse and it’s not better than what the Republicans proposed, it’s the same plan.

    And it’s exactly what the right wanted. It was a gift from Obama and Congressional Democrats just as Clinton and Congressional Democrats gave them DADT, DOMA, NAFTA and the deregulation acts of 1999 and 2000, which created today’s massive poverty, unemployment, underemployment and the disastrous drop in income for workers.

  54. Houndentenor says:

    Last year I needed to see an ENT. I’m a professional singer. No one in my area would take a new patient with less than 30 days notice. I went to a GP because I knew what was wrong and what meds I needed. (In some countries a pharmacist could have taken care of this without need of an MD at all.) And I have a decent insurance plan. (Not top of the line but generally good.) Doctors in this country are full of shit when it comes to dealing with new patients. I wasn’t for single payer until I saw how the insurance companies and doctors acted about ACA. They used it to price-gouge and lie to get people to pay more than they had to under the law. Fuck them all. Single payer is the only way out of this mess.

  55. HematitePersuasion says:

    “Someone who is sick or injured should not also have to worry about
    these other matters, like billing and appointments and such. Quite often
    they simply cannot, so we see this as a necessary health service just
    as much as the treatment or medicines.”

    (emphasis mine)

    Other matters, yes. But that quote does not shift the issue of the illness to someone else, just the other matters. I have no idea if it was intended to include medical decisions or not, but the wording suggests … not.

  56. Houndentenor says:

    I am a student and professional musician. No one pays for my health insurance. I don’t even have any way to buy it through a group except for the uber-shitty school plan and ummm no. There are a LOT of adults like me (maybe as much as 1/4 of the workforce) and yet we are nowhere in the conversation about health care even among democrats. There are a lot of us in between medicaid and great plans offered by big corporations and I wish someone would at least pretend to give a shit about us. So far as I can tell no one in Congress does. I’m not even convinced they know we exist. Every debate on this topic leaves me screaming at my tv which is one of many reasons I no longer have cable. It’s nothing but idiots talking out their asses about things they can’t even be bothered to learn about and I don’t just mean Fox. It’s all of them.

  57. HematitePersuasion says:

    The context of the article “you’re going to get screwed, the grin on the doctor’s face, and the “oh noes!” expression on that of the patient all strongly support that interpretation. Perhaps there’s another interpretation … I would invite you to share it.

    The picture tells a humorous story — very well (my compliments on that to the photographer!). Unfortunately, it’s a story whose punchline depends on the cultural stereotype of anal penetration as being disempowering.

    I don’t see how my text could possibly support any attribution of agreement (or disagreement) with that stereotype on my part.

    For my part, I find the semiotics of the picture unfortunate.

  58. Jim Olson says:

    These things will continue to happen so long as there is any profit to be made from the illness of others. This is why we continue to need to fight for single-payer, nationalized health care, and to give the government the right to bargain with the pharmaceutical companies for the lowest possible prices. Basic health care for all is essential. If, then you want to buy additional coverage, go right ahead.

  59. BeccaM says:

    I remember a revelation when my wife and I were overseas, and she was in need of emergency eye surgery due to a torn retina. We ended up in Bangalore at one of their super-specialty hospitals, a recently build ultra-modern facility crammed full of specialists of all kinds.

    As soon as we arrived, partly because we were foreigners we were assigned a personal liaison, but I noticed early on that the personnel there, once they learned we were together, would speak only to me. When I noticed and commented on the peculiarity, I got a strange look in return. And the comment, “Someone who is sick or injured should not also have to worry about these other matters, like billing and appointments and such. Quite often they simply cannot, so we see this as a necessary health service just as much as the treatment or medicines.”

    That comment stuck with me ever since and now I can’t shake it: The people who most need to make important healthcare decisions are often those who, due to their illnesses or injuries, cannot do so competently. And yet that’s the gist of the message we keep getting from both the “Let them die of pre-existing conditions” GOPers and the “People have to know how to shop for health plans and doctors, no matter how confusing or complicated the exercise” Dems.

    So yeah… the ACA slapped the bandaid of guaranteed issue insurance and much-needed premium subsidies onto the broken U.S. health care system. As someone who has an insurance card now, and who didn’t before 2010, I refuse to say the situation now is worse than what the GOPers would’ve allowed to continue and to degrade further. But, to borrow another metaphor, what we got were a few slapdash repairs to a car that constantly needs expensive repairs, rather than the real solution which would’ve been to replace it with a new one.

    There are plenty of countries in the world with systems that work, including ones with highly regulated private insurance. But we continue to fool ourselves into thinking that laissez-faire capitalism-worshiping approaches are inherently superior — when experience has demonstrated repeatedly that it doesn’t, not when we’re talking essential life-sustaining services like health care.

  60. nicho says:

    Oh, please. The Obamaists saw it coming, which is why they had single-payer advocates arrested.

  61. nicho says:

    And there are some who don’t see anal penetration as “demasculinizing,” but rather enjoy it — or are you saying that gay men aren’t masculine?

  62. docsterx says:

    Unfortunately, that’s not rare and it just doesn’t apply to Medicaid patients. I know a few doctors who treat patients in areas like that. A patient who needs to see a specialist often has to take a whole day off from work to drive 3 hours in each direction to see some specialists. That’s one pf the problems with living in a rural area – if you have severe head trauma, for example, there may be no neurosurgeon for hundreds of miles.

    Some states are making progress with telemedicine. The doctor is in his office wherever that is. You’re in a local doctor’s office, hospital, clinic, etc. with a nurse. The doctor listens to your history, reviews your labs/imaging studies/EKG, etc. has the nurse (or physician’s assistant or nurse practitioner) examine you and give him the results. He may order more tests, or make a diagnosis and treat you all without ever seeing you in the flesh. Of course, that doesn’t work all of the time. Sometimes you have to be seen by the doctor, go to an ER, etc. Might be something that you want to look into. See if there are telemedicine services available in your area.

  63. HematitePersuasion says:

    What’s up with the picture that accompanies this article? Ha-ha, you’re gonna take it up the butt from your insurance company? I mean, it’s a little thing, but … it surprised me. Aren’t we better off without that kind of casual reference to anal penetration as a desmasculinizing metaphor?

  64. nicho says:

    And even in the accident-based insurance policies, their goal is to find some way to not pay out when what you’re insuring occurs. That’s how they make their money.

  65. The_Fixer says:

    The big problem is in how we treat health care in turning it over to the insurance companies. Insurance companies, as they have traditionally been defined, are there to pay out in the event of an accident. They place a “bet” that you won’t get into an auto accident, have a hailstorm ruin your roof or have a neighbor fall on your sidewalk and suffer injury

    Health care is not an accident, it’s a totally different set of circumstances. Sure, the intent is that the insurance company “bets” that you won’t contract some disease or develop some chronic medical condition. But that is the wrong way to look at it.

    We all need varying degrees of medical attention at some point, whether it is as a result of an accident or not. It’s a given. Then why are we looking at medical care as something that only needs to be provided on the basis of a roll of the dice?

    A publicly funded health care system is the only sensible way to pay for health care. The government’s job is to provide for the safety and security of its citizens, and to assist in making our lives better. Providing health care falls perfectly in line with the mission of government.

  66. nicho says:

    Well, if they’re profiling on the basis of citizenship status, you should report them to the state board of dentistry, or whatever regulates the industry in your state. This is illegal.

  67. Bill_Perdue says:

    Some of the largest health insurers are hitting all-time highs. … Shares of UnitedHealth Group (UNH +0.74%), Humana (HUM +0.91%), Aetna (AET +0.94%) and WellPoint (WLP +1.73%) rallied Wednesday — with all four recording all-time highs in the wake of the Obama administration announcement that total enrollment in Affordable Care Act health exchange plans now tops 5
    MSN Money March 20th, 2014–insurance-stocks-soar-on-obamacare-sign-ups

    That is all you need to know about why Obamacare/Romneycare was imposed on working people.

  68. Bill_Perdue says:

    That lack of foresight was deliberate. The passage of Obamacare/Romneycare was ensured by liberal bribes in the form of campaign ‘contributions’ and a couple of dozen secret meetings between Obama and the owners or managers of insurance and Pharmaceutical companies.

    The passage of Obamacare/Romneycare is a step backwards because it maintains the status quo.

  69. just_AC says:

    I got questions –
    1: I live in a rural area – what if there are NO specialists under 3 hours driving time?

    2: you think this is bad, try getting an adult medicaid dentist! I was helping out a friend yesterday – the closest one was only 1:45 away. Unfortunately, they are only taking migrant workers at this time. In October, they MAY start taking Americans. You have to call a week in advance to set up appt (so, Tuesday morning for next Tuesday) Start calling at 8:00 AM and keep dialling until you get through. Hopefully, they may have an appointment available.

  70. nicho says:

    Any “health care” scheme that keeps insurance companies in the loop is a failure and that includes “Medicare for all.” Anyone who touts “Medicare for all” doesn’t know how Medicare works.

  71. emjayay says:

    Obviously this is exactly the problem with all kinds of competing for-profit (or not, for that matter) insurance companies making all kinds of deals with drug companies and constantly adjusting their terms for the insured in order to keep making a profit, as the competition also changes their deals. If you don’t just run the whole thing or a component of it nationally, this is what you get – confusion and high costs of oversight.
    Meanwhile, for ongoing prescriptions, the two insurance companies I have had both had a mail order deal where you get three months for the price of two. Kaiser Permanente, my previous health insurance (in DC and SF, not NYC) a real HMO, runs their own pharmacy on site.
    With the two for profit insurers I have had there was never a problem finding out copays etc. I could get the formulary in print, see it online, check actual prices online, or call. And these are two not particularly highly rated ones.

  72. lynchie says:

    I think oversight is the correct term. If they weren’t bright enough to think of all the ways the insurance companies would find loopholes then the wrong people were in charge. I wonder who is policing the % of profit compared to coverage that was built into the ACA. If there is no oversight (which i doubt there is) it is business as usual. These companies are built around profit not providing care for their patients/customers.

  73. Indigo says:

    My concern is not so much that the insurance companies did that but that the authorities naively did not see it coming and build in firewalls to prevent that kind of manipulative exploitation. The lack of foresight bothers me.

© 2021 AMERICAblog Media, LLC. All rights reserved. · Entries RSS