As a journalist and parent, I've had a front-row seat to the “complexification” of American healthcare, which demoralizes and depletes users. We have to fix it - or at least not make it worse.
Julie Marquis is a recovering journalist of four decades who now pays attention to her family. A veteran of the LA Times, KFF News and Reuters, she led teams that won a Pulitzer Prize for Public Service and a Selden Ring for Investigative Reporting.
Thirteen years ago, my spouse quit her job as an attorney to care for our family, including two girls we’d adopted in middle age. She envisioned escorting them to zoos, museums and playgrounds, maybe grabbing time here and there for herself.
We laugh about that now, sort of. One of her main hobbies, if you can call it that, has become struggling to make sense of our healthcare coverage. Now in our 60s, we’ve had a front-row seat to what I call the “complexification” of American healthcare, a needlessly disjointed and sprawling system that demoralizes and depletes its users.
We’ve only recently plunged into the world of Medicare and its many gaps, but our family – which includes a daughter with a serious neurological disability – was covered for years by employer-provided private insurance. Though our experience pales in comparison to those who fall into medical bankruptcy or rely on Medicaid, it has again and again made me wonder why this country allows such a flawed system to persist.
As long as we are protesting things in America, why don’t more people take to the streets about this?
It remains to be seen whether Democrats can rouse the populace over cuts to publicly supported health coverage by making this the central issue in the government shutdown. In the private sector, the unseemly rejoicing over the murder of United HealthCare’s CEO last year showcased the rage many Americans feel toward insurance companies and their denials. Premium spikes are on the way and could galvanize voters. Yet comprehensive reform efforts have failed at least since the 1940s, when Harry Truman’s proposed national plan tanked and coverage became ensconced as a job-based “fringe benefit.” Now the U.S. is alone among comparable nations in lacking universal coverage, and its system remains singularly inequitable, expensive and inefficient.
Week in and week out, families like ours do a slow burn. And if the system is challenging to us – I was a long-time healthcare journalist, and my spouse is a 40-year devotee of Consumer Reports – think of how much worse millions of others have it.
For our part, we were exasperated by “Explanations of Benefits” that were often indecipherable. We were frustrated by unreliable advice from the faceless individuals who fielded our calls to insurers after we repeatedly said – then screamed – “representative” into the automated system.
A few examples from our lives
Two family members see psychotherapists weekly. Under my employer plan, we paid hundreds of dollars upfront for 45-minute sessions, then fought for any reimbursement we could get. That’s because our therapists were among many in Los Angeles (and other areas) who were “out of network” or didn’t take any insurance, preferring not to hassle with billing codes, delays and denials.
Over the years, under various private plans, our reimbursements became slimmer and more inconsistent. Sometimes plans paid; sometimes they denied identical submissions; and sometimes they said our claim was not received, was illegible or got stuck in the wrong department.
We also had problems with in-network coverage. One daughter was treated for a Vitamin D deficiency. The doctor ordered a retest to see if it had been resolved, but a lab or office clerk supplied the wrong diagnostic code – the route to billing hell.
The claim was denied, forcing us to pay the lab. We were told we had a year to resubmit it ourselves. We did so, only to be denied again because, the insurer said, the window was actually six months. We could appeal – most appeals succeed – but one must measure the potential gains against growing battle fatigue. “Insurance companies bank on the fact most patients won’t appeal,” says Larry Levitt, an executive vice president at KFF, a San Francisco-based nonprofit that researches and reports on healthcare.
Short of filing formal appeals, we sent 14 letters to my job-based plan in the last three years, with pleas, sometimes in enlarged type, to act on a claim or stop making the same mistakes. We painstakingly cited plan policies or even case law. In one instance, more than $8,000 was held up because, in a seemingly immutable corner of their bureaucracy, we were erroneously marked as unmarried.
Medicare hasn’t provided much relief. All spring our den was covered in piles of annotated paperwork as three of us, including one daughter (who qualifies because of her disability), prepared to fully enroll. Suddenly, like other saucer-eyed seniors, we faced what Levitt describes as “a blizzard of decisions.”
Mistakes come with a cost. If you’re late in enrolling for parts of Medicare, you may face a lifetime of financial penalties. I get it – the government doesn’t want folks signing up when they’re sickest – but woe to you and your wallet if you miss those deadlines.
You quickly learn that Medicare, as traditionally conceived, is far from all-inclusive. You are on the hook for services it does not deem “medically necessary” like routine dental, foot, hearing and vision care. You typically must also pay 20% of approved nonhospital medical, or Part B, costs.
Medigaps, indeed
Another surprise: The traditional program does not cover routine annual physicals. Instead it pays for hands-off, half-hour “annual wellness visits.” These focus on future planning and prevention rather than diagnosing existing problems. If that confuses you, it also confuses and frustrates doctors and billing departments, which means some offices, including my disabled daughter’s, won’t do them.
Once every five years, traditional Medicare pays for preventive blood screens to detect cardiovascular risks. Bad news for seniors, since at our age, we are more likely to develop such problems, which are best detected early. Fortunately, I learned of my rising LDL cholesterol and triglycerides a few years ago, from a blood test covered by my job-based insurer. I went on a statin then.
To fill holes, private insurers hawk Medicare Advantage or Medigap policies, with their own rules and restrictions. Many people decide this alone. We took a look online at the screens of ads and side-by-side comparisons and called a broker. Weeks later, we chose a Medigap plan. I was grateful to be spared interaction with the government’s allegedly error-ridden Medicare Advantage plan directory and possible enrollment in inadequate networks.
Soon enough, however, we learned Medigap’s limitations: It doesn’t provide extra benefits. It’s generally a complement to Medicare, covering out-of-pocket costs linked to Part A hospital and Part B medical care. We had to buy separate plans – Part D – to cover prescription drugs.
‘Rationing by Red Tape’
The complexity of this process was numbing. I had to force myself to stay alert as our broker detailed how switching Medigap plans after your initial six-month enrollment period could raise your lifetime costs or imperil your coverage. Fortunately, you can, at least in California, change to a different plan with the same or lesser coverage once a year within 60 days of your birthday. Got that?
At times, these convolutions felt insane; at other times, strategic. According to Levitt, some of the tribulations suffered by U.S. healthcare consumers stem from “a deliberate effort to discourage people from accessing” care. He titled a recent lecture on the subject “Rationing by Red Tape.”
Why is reform so elusive? Largely, it’s because U.S. healthcare is gargantuan – not one system, but many, built on layers of slippery and imperfectly laid bricks. Politically, medical coverage is not a wedge issue like guns or abortion. At the same time, healthcare is the largest employer in the United States with an outsized role in the economy. Because the system has many vested interests, middlemen and constituencies aligned against change, it is tempting to conclude it is too big and entrenched for wholesale reform.
To me, a single-payer system makes sense. But at the very least, let’s not go backward by gutting the programs we already have. Imperfect though they are, Medicaid and the Affordable Care Act together cover about 120 million people and account for the most progress we’ve made over the last 60 years. Now is our chance to fight for them – and Medicare too, before the current administration pares it to the bone, shortchanging its 68 million beneficiaries. These programs can be simplified, standardized and expanded without ending private insurance.
We are entitled to a basic, transparent level of coverage that isn’t designed to exclude us, trip us up or bankrupt us. Shrinking coverage and blocking claims while raising prices isn’t an acceptable business plan – not in a system that holds our health and ultimately our lives in its hands.