Medical Insurance and our Health Industry

As a person who has worked as a healthcare provider and a health insurance claims processor I am in a unique position as a person of integrity of having seen all sides of the health industry and it isn't pretty.

We should never forget that Medical Doctors, Hospitals, and Insurance Companies all exist to funnel more money back into Big Pharma, the AMA, Hospital and Insurance Company upper management and owners.  The product they sell is not health, but the treatment and care of people with injuries and disease.  This is also true about the Charities that raise funds for people with particular diseases. It is why we are not going to see the cure for cancer, or the cure for anything for that matter, come out of Big Medicine.

Insurance companies, like Blue Cross and Blue Shield, were founded by Medical Doctors, retired Medical Doctors, and their families.  If you wonder why a particular treatment or diagnostic procedure isn't covered by insurance, ask yourself how much money Big Medicine could potentially gain or lose if that item was covered.  Follow the money and you will have your answers.  Thermography isn't covered by insurance, although it is a healthy alternative to certain radiograms, because it would take money away from mammograms.  Chiropractic and naturopathy are generally not covered in most policies.  It is important to keep this in mind as we examine the details of insurance coverage.

The Affordable Care Act works like this:  In order to qualify for being an "ACA endorsed" insurance policy, the policy must follow coverage as outlined in the ACA.  There are 10 points of coverage (listed below).  A citizen of the USA who is not covered by an ACA approved insurance policy, pays an extra penalty, a tax to the US government for not buying that coverage.  In other words, the US government is forcing you not only to buy health insurance, but a health insurance that has been stamped with their approval.  Does anyone see a potential for conflict of interest here?

If you are the typical USA-educated citizen with little or no health education outside whatever you learned in public school, and you trust that medical doctors and our government have your best interest in mind, this sounds reasonable at the outset. But here's the catch:  you are already paying for insurance premiums.  In some cases those premiums could be your highest monthly bill just after mortgage or rent.  If you discovered that a particular therapy was covered by your insurance, but another therapy, one that would be better for you, is not; what are you going to do?  If you have disposable income, you might go for the better therapy.  Lots of people don't have disposable income and now that you are being forced to pay for medical insurance that does not cover what you really want, you have less net income.

For example, I have not been able to work since my husband's death.  My only income is $1700 per month "survivor's benefits" through Social Security.  That is $500 more per month than what would qualify me for "Apple Care".  In other words, I would need to have an income of less than $1300 monthly as a single person without dependents to qualify for reduced rate insurance.  The lowest priced qualifying plan for ACA, without discounts, costs $550 per month, without dental insurance.  That plan has a $6000 yearly deductible.  So basically, unless I get hospitalized for an accident, I will be paying $6600 in premiums per year for mandatory insurance I cannot use.  I pay out about that much money yearly in health care, but I pay to Chiropractors and since Chiropractic is not a covered benefit on that plan, those fees are not counted toward my deductible.

Insurance companies all play a crooked game called "UCR" (Usual Customery Reasonable) fee.  It is rare for any item to be covered one hundred percent by insurance.  Good insurances usually pay about 80% of standard fees for most services that are covered.  But that 80% is based on a survey that may be more than 5 years old, and, like gerrymandering, may be based on a geographic map designed to produce a lower UCR amount.

obamacarefacts.com/obamacare-health-insurance-rules

Here is the list of 10 criteria that each policy must cover in order to qualify for ACA.

1. Ambulatory patient services.  Any time you walk into a Doctor's office, this is the type of care you are receiving.  This care is subject to your yearly deductible.  There is also a wellness benefit (number 9 below) which overrides the deductible. 
2. Emergency services.  Subject to yearly deductible.
3. Hospitalization.  Subject to the yearly deductible.  This covers the cost of the hospital stay, not the Doctors' or lab fees or incidentals, just the cost of being in the bed with nurses nearby.
4. Maternity and newborn care.  Subject to the yearly deductible.  This coverage is mandatory, whether or not you are a woman of childbearing age and whether or not you choose to have children.
5. Mental health and substance use disorder services, including behavioral health treatment.  Subject to the yearly deductible.  This coverage is mandatory, whether or not you smoke, drink alcohol, have an eating disorder, or mental health issues.  Yes, grief counselling is covered, the agent assured me; subject to the $6000 yearly deductible.
6. Prescription drugs.  These may not be subject to yearly deductible, but they are paid at a rate determined by the insurance company.  Some prescription drugs are not covered.
7. Rehabilitative and habilitative services and devices.  Subject to the yearly deductible.
8. Laboratory services.  Subject to the yearly deductible.
9. Preventive and wellness services and chronic disease management.  Some of these are not subject to the yearly deductible, you need to check your individual plan.
10. Pediatric services, including oral (dental) and vision care.  Dental coverage for children is a requirement for all plans.  Subject to the yearly deductible.

Now suppose I wanted to make a plan for me?  It would cover dental, and vision, chiropractic adjustments, naturopathic care, and hospitalization.  I wouldn't bother with prescription drugs because I don't take them.  Nor would I cover laboratory services, because I have my own urine and blood testers and they are faster and cheaper done at home.  I don't get mammograms because I believe they give people cancer.  I'm not interested in maternity services nor pediatric services.  The preventative and wellness services is the same as my chiropractic and naturopathic services so I wouldn't need an additional benefit for those.

Unfortunately my specially tailored insurance plan doesn't exist, nor will it ever.  Why?  Because of who owns the insurance companies. 

So barring being able to purchase my dream plan, what is it I want?  Just hospitalization and rehabilitative therapies; in case I get into an accident.  I want that insurance for about $250 per month and it can have a $6000 yearly deductible.  That way, I'd be paying all my regular expenses out of my own pocket but I wouldn't be paying for stuff I can't use.  And you know what?  THAT insurance exists.  It even has a few other benefits thrown in, but it doesn't qualify as an ACA plan and I'd have to pay the tax penalty for buying it.

PUT MORE ABOUT HOW PPO PLANS DRIVE UP MEDICAL COSTS HERE.

PUT MORE ABOUT WHAT TREATMENTS QUALIFY AND HOW THAT IS DETERMINED HERE.