Thursday, October 8, 2009

Five Reasons for Health Insurance Reform

Somewhere during the summer, health “care” reform switched to health “insurance” reform, and the debate came alive in new ways. While our system of health care itself is worth questioning, in fact vigorously by some, including Michael Moore in his award-winning film, Sicko, what makes a lot of sense now is challenging the way we package health care, pay for health care, withhold health care, dole it out. And, when looked at in that light, “insurance” is definitely the aspect of our health system that needs reforming.

As we make changes to Capabilities, separating ourselves from selling products, while highlighting still the importance of access to products and services that promote independence, the voice I use in this blog will change sometimes. Ever interested in putting a whole picture on the table, I have particular experiences that do shape my perspectives and beliefs. I am not always neutral on these matters of great importance.

To insist that our health care insurance options today should be the choices of tomorrow ignores some realities that are out there, maybe not for all of us, but for enough of us Americans to take notice. I have five situations (at least) that make me believe that the time is now to change some fundamentals about health care and health insurance. I have changed the names to protect privacy. The situations are real, though, and some version of these situations presented themselves on a nearly daily basis.

  1. Mike, a 40-something, has a debilitating disease made all the more complex by premature arthritis that causes severe spinal and hip pain. He lives on SSI disability income and Medicaid. In this case, he has options that some others do not. Medicaid has paid for a wheelchair, a patient bed and equipment for the bathroom. He cannot sit or stand for any period of time, however, and he needs a chair, a reclining lift chair. Medicaid will pay for one of those, too. The approved one. Mike has tried that chair under several conditions and it causes him excruciating pain. He has found the one that works for him. Medicaid will not approve this chair; they approve the other chair and deliver one to him. He does not use it. They will not take it back. He called to tell him he just cannot sit in it.
  2. At 84, Margaret could no longer manage her day-to-day activities in her home. After discussion, her family and she decide that if she had a power wheelchair to get around the house, she could stay at home longer. Margaret and her family worked with one of those dealers advertised on TV, who made it easy for her to get approved, advising her how to work with her own doctor or providing one in their networks. They sent her a chair. It was too big for her home and for Margaret. Her family tried to work things out with the dealer, but to no easy avail. Margaret passed away a few months later. The family now has a big power wheelchair. They are trying to sell it. “It’s a $6000 chair,” they say in the ad. Everyone knows they did not pay a penny. Medicare footed the bill for something that proved useless for Margaret.
  3. Gloria is barely 50. She lost her job with the downturn. She has fibromyalgia, a syndrome that causes myriad physical problems, including mobility issues. She also lost her insurance coverage because the COBRA payments were too high for her to continue the coverage as properly offered by the company. Within a few months, with still no job prospects, Gloria’s condition worsens. She needs a walker to get around the house and something more powerful when she goes out to look for work. She cannot afford even the basic one. She spends her time looking for a donation and applying for grants at local churches. Her job search falls by the wayside.
  4. Jose became an American citizen years ago and worked diligently to provide for his family. He paid his insurance premiums faithfully. At age 60 and a widower, he struggles with COPD, diabetes and congestive heart failure. He cannot work anymore and after the COBRA coverage ran out, he tried to buy individual coverage. Because he has pre-existing conditions, he is not insurable. Luckily, he had savings. They are used up now, so he sold his home to be sure he can buy oxygen, a must-have to get through his days.
    Jim and Alice are about to bring Alice’s mother in to live with them. She has advanced macular degeneration leaving her nearly blind. Her children want very much to find her some tools to help keep her active. A CCTV costing about $1700 would give her enough independence during the day while Jim and Alice work to read, do her needlework and write checks to pay her bills. Surely, insurance will help cover this needed tool that will give Alice’s mother some quality of life? Jim and Alice get very angry when they learn that neither Medicare, nor the high priced supplemental insurance she has, will pay anything towards vision tools, other than corrective lenses, exams and surgeries.

    I have seen hundreds of people disappointed, angry, frustrated and despairing when they find that “after all these years of paying into insurance” they are left to handle the situation themselves. Of course, health insurance does pay for certain procedures and pieces of equipment. And for those who have great coverage, the complaints are few. But, there are things so necessary, so vital to quality of life, to mobility, to independence, to comfort, to managing pain that individuals pass up every day, or sacrifice even more to get. In more certain times, adult children, grandchildren, nieces, nephews have taken up the slack, filling in the gaps to ensure the right thing happens. In these difficult economic times, everyone thinks twice before opening a wallet, including loving and caring family members.

    Reason tells us that we cannot as a country satisfy every need and comfort. After these years of working with honest, hard-working families who face physical challenges that may lie just around the corner for every one of us, I am more persuaded that there is a place for oversight and regulation of health insurance at the very least, and perhaps even a greater role for government to ensure that the list of health care basics for every American gets redefined.

    One interesting idea is to shape the health insurance industry after the public utility model. While privately held companies can compete to deliver electricity, for example, there are guidelines and regulations that ensure a modicum of fairness in access to the utility, pricing and safety.

    What do you think? What gets under your skin about health care and health insurance? What do you like about the way things are? Please post your comments here or email.

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