Our Health Care System – An Insider’s View

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Upon completing college back in the early 1970s, I worked for a large department store in NY in the accounting office. Working full time, naturally, I was afforded a company group insurance policy which included health benefits, along with dental, and life insurance. At that time there were no HMOs, nor were there any physicians that did not accept any legitimate health insurance plan. During my childhood, my parents always maintained insurance coverage on both me and my sister through Blue Cross/Blue Shield of NY. The insurance offered by my employer was also through Blue Cross/Blue Shield of NY. It was touted to be the best health insurance plan around at that time, and cost me personally nothing to enroll. The employer paid the entire premium in my behalf, and although it did have a yearly deductible, and then paid 80% up to a specified amount before paying 100%, being relatively healthy it posed no real economic hardship on me, and I was easily able to cover my deductible, and small out of pocket costs for any tests or prescriptions I may have needed.

It wasn’t until I relocated to southern California in the mid 1970s, that for the first time, I realized just how much our country needed to revamp its health care system. Perhaps revamp is a poor term for what I observed initially, but eventually it would become a very well suited term for what would be needed. Of course today what is needed is a complete overhaul of our health care system, and a program that will allow everyone affordable and good quality health care. However, intiially, the programs in place were very good, and very affordable to those who worked full time. There obviously weren’t as many small businesses out there, and even the ones that were, could at least afford some type of health care coverage for their families. While I was living in southern California I met and married a young woman who had been afflicted with a rare form of Muscular Dystrophy, and was on Social Security Disability and State Supplemental Income. In addition she had Medicare and Medi-Cal to help pay for her medical fees and services which she desperately needed to keep her alive, and functioning.

Even back then, it took almost an act of Congress to qualify for those programs, and you had to have a redetermination every two years to see if your conditions had improved. Every two years my wife was subjected to an independent medical exam with a Medicare approved physician who reviewed all her medical records for the previous two years, and examined her, and then reported his or her findings to the Social Security Administration for review with his or her recommendations. Although my wife’s condition was only getting worse, and other than short periods of remission where her disease was in check, she was basically declining, and it was obvious it should would never be cured, still she would continue to be subjected to these exams every two years until her death in 1988. In was during this period of time that I personally became involved in the health care field, and saw first hand just how insurance companies worked, at least when it came to health care.

In 1981, I obtained a position at a very well known Hospital and Health Care center in southern California. My job was that of a Patient Financial Counselor, which entailed the discussion with patients and/or their families either prior to admission, during admission or at discharge, in order to work out arrangements for payment of the unpaid portion of their hospital bills. In most cases the balance owing was anywhere from a few hundred dollars to couple of thousand dollars depending upon the procedure done and the amount of time actually spent in the hospital. If the patient was covered by a good private insurance carrier, it was usually only a few hundred dollars. In the case where they were covered by Medicare of Medi-Cal, they ofter owed nothing. If they were indigent, and had no insurance at all, we had a social worker on staff who would attempt to get them on some form of emergency medical assistance to help pay their debt in full. However, that would soon all change with the cut backs in Medicare, and other social programs during the course of the Regan Administration. By the mid to late 1980s, insurance carriers were demanding second opinions on certain procedures, and PPOs and HMOs began to spring up all over the country. It was the beginning of managed health care, which has its own pros and cons. The biggest advantage to the employers who provided these programs to their employees of course was the costs. Costs for PPOs and HMOs were much less expensive than the traditional health care plans, and saved the employer thousands of dollars per year in costs. It was the biggest selling point for them, but left many employees with less than adequate coverage.

If an employer for example opted for an HMO plan, the employees found themselves in many cases looking for a new doctor as their doctor wasn’t a part of the HMO plan. At least with the ones who lucked out with a PPO plan could still see their own doctors of choice. The insurance just didn’t pay as much as they would if the physician was enrolled in their plans. With the HMOs, you had to sign up for a primary care physician who had to be a participating physician in their plans, or they would not pay the doctor’s fees. In addition if you had to see a specialist, your primary care physician had to get an authorization from the insurance carrier for that visit. The same held true for many procedures you may need to have, and again it was up to the primary care physician to get prior authorization, or the patient was stuck with paying the entire bill. It was during this period that medical groups or clinics began to spring up all over the country, owned and operated by the HMOs. It was their attempt to control health care costs, and manage health care for its patients. Since the inception of HMOs there have been all types of lawsuits filed against the HMOs for wrongful deaths and for lack of necessary treatment for their patients, but still they are going strong.

The question I pose is, when does good health care offset the costs? If a doctor deems it necessary for a patient to undergo a long medical treatment plan to help save their lives, or to give them a better quality of life, costs should be of secondary concern, and the patient’s well being should be placed first. Unfortunately, that is not always the case. Yes, I agree that there are people who abuse the system, and run to the nearest emergency room for every little ache and pain when they are covered by a public medical program such as Medicare and Medicaid, but what about the ones who truly do have a need for emergency services, and often have to wait hours to be seen because the emergency room is filled with non emergent cases simply because they know they cannot be turned away just because they have no insurance or public insurance programs. The publicly funded programs such as Medicare and Medicaid need to start to review these non emergent cases, and refuse to pay for those services making the patient liable for any and all costs incurred for those visits.

In the 1990s, during the Clinton administration there was a push on for a complete overhaul of the health care system in this country. The concept behind the idea was to find a feasible way to offer affordable, good quality health care to all Americans, not just those who could easily afford it, or those who were already on publicly funded programs such as Medicare or Medicaid. Additionally, there was a proposal that would allow the insurance companies to receive government subsidies to offset the costs of insuring those who were considered to be high risk, or chronic patients. Several models were investigated, and in an effort to destroy any hope of resolving this issue, lobbyists and special interest groups claimed that it would be a form of socialized medicine and costs taxpayers billions of dollars, and would not necessarily offer better quality health care. In the end the only positive thing that came out of the whole deboggle, was guaranteed health care for children, and the allowing of either parent to take time off from work after a child’s birth without fear of losing their job or seniority. Even the bill which affords health care for children needs additional funding and has been lacking due to political pressure and budget restraints over the past several years.

In recent years we have been so concerned about fighting terrorism around the world, and our military and political efforts in Iraq and Afghanistan at the cost of billions of dollars, that the overhaul and reconstruction of America’s health care system has been put on the back burner. Even with a Democratically controlled Congress, the health care system has not gained any further support, nor has it been placed on anyone’s priority list. Only in recent months with the primary elections has the question of providing affordable health care for all Americans once again resurfaced and been placed on the candidates priority lists. There is no question in this author’s mind that something has to be done to protect Americans from the high costs of health care, and the ability to receive good quality health care services no matter what the persons financial situation. I am not proposing a socialized medical system, nor am I in favor of allowing non citizens to have free participation in any such system devised. However, for those hard working Americans who hold down jobs and pay their taxes, and especially those with families, need some type of guarantee, that they can obtain good quality health care when they need it, and at an affordable price.

No one wants to see people dying or not enjoying a good quality of life just simply because they cannot afford to see a physician when they really need to, or afford their medication that keeps them alive or in good health. However, we cannot afford to keep going the way we are just because we are a free enterprise system and allow for competition between businesses. While the health care industry is a business, just as with public utilities, the government does put controls on prices and price increases, and perhaps a similar program with the health care industry would work the same way. I just have a hard time swallowing the fact that we have billions of tax dollars to spend overseas on wars we can’t win, or have no reason to be involved in, other than the stuffing of someone’s pocket, yet we cannot provide affordable quality health care for our own citizens here at home. While this may be just my opinion, I think that there are many Americans out there who feel the same way, but believe that we are in the minority, and that no one in Washington, is really listening to us. Perhaps this next national election will show the bureaucrats in Washington that this is not the case, and really send a message to our political leaders that it is time for a real change.


Source by Mark Sacks



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