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Is Any Illness Covered by Insurance?


(I originally posted this at Daily Kos, where it is on Recommended list. The issues are national, but also local.  And keep in mind that our Governor and legislature will be fighting the legislation.  As I promote this I note that Caucus Chair John Larson announced on ABC that the Dems now have the votes.   – promoted by teacherken)

“Chronic means a medical condition which has at least one of the following characteristics: has no known cure; is likely to recur; requires palliative treatment; needs prolonged monitoring/ treatment; is permanent; requires specialist training/rehabilitation; is caused by changes to the body that cannot be reversed.”

That is the definition received via email by Nicholas Kristof from Sophie Walker, the group head of claims for Interglobal, a health insurance company based in London.  Kristof was, as he describes in his column this morning, calling to understand why a family he knew, who thought they had a coverage limit of $1.7 million, was cut off from further benefits because of a “chronic condition” for which the benefits were capped at $85,000.  

When he further asked what serious disease the company did not consider chronic the chief executive responded that because he was “disappointed”  at the “tone” of Kristof’s inquiry it would have no further response to his questions.

So the question of our common title still stands, for this company, Is Any Illness Covered by Insurance?

The couple in question is American, currently living in Hong Kong.  Before relocating they sought out a policy that would provide them coverage.  The premium cost for the wife and two children seemed reasonable, $4,500/year (the husband was covered through his job).  The world of these former neighbors of the Kristofs collapsed when the wife was discovered with late-stage stomach cancer.  The stomach was removed, Jan (her name) was received chemotherapy, but it was discovered that her cancer had spread to her intestines.  And the company informed the family that their costs were no longer covered after $85,000.  

Kristof reminds us how preposterous tour current system is:  

we rely on insurance companies whose business model is based on accepting premiums from healthy people and devising ways to exclude from coverage those who most desperately need medical care.

He says bluntly that those who say emergency care is always available rings hollows to a woman with stomach cancer, and simply is not a sustainable way of providing health care to the 75 million Americans who are either un- or under-insured.

Let me stop right there.  Several points that need to be discussed.

1.   Resorting to emergency room care is expensive.  Yes, you cannot legally be denied treatment in a certified emergency room, even if you lack insurance.  But the hospital recovers those costs by passing them on as overhead in charges to those who are insured.  That raises the cost to the rest of us.  And simply put, conditions are treatable for far less outside of emergency rooms if we do not wait until they are crises.  I do not know of a better illustration of the old saw of being penny wise and pound foolish.

2.  Note that figure of 75 million.   We currently hear about the 30-40 million who are uninsured.  But that understates the crisis.  Being underinsured is as critical, and is a major reason why so many personal bankruptcies are filed by those who have medical insurance but find in a crisis it does not sufficiently cover their bills.  If you are underinsured you may still postpone receiving medical care that is not fully covered, have it blossom into a major situation, and then in bankruptcy there are further disruptions and additional expenses for legal fees and the like.   And if the bankruptcy successfully discharges the obligation for the one filing (in part or in whole) that “loss” is passed on to the rest of us in higher fees (including the legal fees) in what we are charged in our insurance premiums.

Kristof has a number of powerful statements in this piece, reminding us, for example, that It’s in the interest of insurance companies to exclude people who are sick, while it’s in our national interest to see them covered..  He quotes a landmark study from the Institute of Medicine which says bluntly “The absence of health insurance is hazardous to your health.”   He tells us that in Kentucky women without insurance have cancers detected later than those who do, and that those without are 44 percent more likely to die of breast cancer.

I will be 64 in about 2 months.  Thus it caught my attention that

for American adults ages 55 to 64, lack of insurance is “third on a list of leading causes of death for this age group, behind only heart disease and cancer.”

  I have insurance through my employment, so I do not face that risk.  But I am a teacher.  And across the nation teachers are receiving layoff notices as states and local governments scramble to balance their budgets.  When those teachers –  and other government employees – are laid off, they also lose their health insurance coverage.  

For some reason, reading this column reminded me of an episode of Law and Order.  It involved an insurance company in Europe selling life insurance policies to Jews knowing that they would not be able to collect.  It was a kind of fraud.  I do not remember if one was required to be able to produce a death certificate to collect, and in a sense that is irrelevant.  If a legal system allows a company to sell what purports to be a kind of insurance but also allows it to word the policy such that an ordinary person has no way of knowing that s/he will not be able to collect on what seems like a covered claim, if that is not fraud, the law should be changed so that it is defined as fraud.  Operating in such a fashion is immoral, and cruel.  

And perhaps this is the difference between those who advocate for a pure market system and those who understand the need for government regulation and even intervention.  Adam Smith’s model of pure free market capitalism requires perfect knowledge by all participants.  Unless you have expertise in medicine, law, and similar fields, attempting to find appropriate and affordable insurance leaves you vulnerable to companies like InterGlobal, willing to purport to insure you but equally willing to find any excuse to deny your claim.

The health insurance reform that will, hopefully, pass the House later today, is only a first step in needed reform.  

Only a first step, because ultimately we need to step back and understand an important principle.  From the standpoint of a for-profit entity, it makes all the sense in the world to look for reasons to deny claims.  Putting an unlimited profit motive upon something as important as health care is immoral, and dangerous.  It is dangerous because it leads to people not being covered –  such as undocumented aliens, for example.  That is equivalent to leaving a section of the population not inoculated against a highly infectious disease, increasing the chances of an epidemic outbreak.

Immoral.  Also financially irresponsible.  As noted about the costs of emergency rooms.  We will pay those direct costs in our own insurance.  Unless we are then going to be “financially responsible” and begin to deny emergency room coverage to the uninsured.  After all, that would be a logical reducto ad absurdum of a mindset that says none of this should be the business of the government, that in some cases would go so far as to be willing to abandon public education completely, or at least refuse to provide the assistance necessary to educate children in poor communities, or with disabilities, or who need language assistance, OR WHO ARE UNDOCUMENTED ALIENS –  so far we allow the last to be educated in public schools, but we are willing to deny them health insurance.  We do not YET deny them access to emergency rooms, so again we are penny wise and pound foolish.

This is not the topic about which I expected to write today.  This is Bach Day, the 325th anniversary of the birth of one of mankind’s greatest geniuses, Johann Sebastian Bach.  I would love to have had my focus on his music.

Yet in reading Kristof I felt this was more important.  Perhaps by the time I post this, it will already be covered in the Pundit Roundup at Daily Kos.  If so, great.

That does not free me from the responsibility to discuss the issues it raised for me.  

Today we will, from all evidence, take a major step towards fixing our broken health care system.  It will be major, but only one step on a much longer journey.  

I used Kristof’s title as my own:  Is Any Illness Covered by Insurance?    In fact, if ANY illness is NOT covered by insurance, at least to ameliorate the suffering, then we have an insufficient system.

We should never have to ask the question of the title.  In fact, we should not even have to ask Is my illness covered by insurance?  

We all feel the effects – at least financially – of those for whom the answer to the last question is NO, even if they have paid a policy.  And if we turn away, if we do not fix the system, we will have no right to complain when at some point insurance for us or someone close to us is terminated, perhaps by loss of job, perhaps because of rescission, or – even worse – we are told that despite years of paying premiums the answer to the last question is NO, that this illness/condition is not covered, we are on our own.

Happy Bach Day.  Let’s pass the bill today.  And then let’s fix it.  Let’s understand that we cannot afford, financially or morally, to do anything less.



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