life as understood

by jeff carr, master of the arts, -------------------------------------------------------------------------- presumably from a couch


three stories about the health care system

courtesy of Jeff |

Maybe it should be story problems, like in math class. Sure, let's do that.

Story #1:
Thanks to the Affordable Health Care Act, an attractive young woman -- let's call her Tara* -- returns to her father's health insurance through Insurance Company A. She's married, but under 26, so it's cheaper that way. Then, despite a hearty birth control regimen, she becomes pregnant.

Certain health issues make hers a high-risk pregnancy, and she could legitimately give birth anytime from March to May. In late March, after one or two labor scares and hospital visits, her father receives word that his company is switching everyone over to Insurance Company B, effective April 1 -- almost immediately.

Tara is in no position to switch doctors or providers at this point, especially since she has been receiving special high-risk care, and she knows the baby could come anytime before or after April 1. And besides, pregnancy is a clear pre-existing condition that she is assured will be covered by the new plan. Tara is issued a brand new Insurance B card on April Fools' Day. Four days later, she gives birth at Hospital AB, the only option afforded by her provider.

Thankfully, mother and baby are reasonably healthy, despite negligence on the part of Hospital AB that requires the baby to be re-admitted and placed in the NICU at Hospital K less than 48 hours after discharge.

Months later, Tara learns that her father's company, under the new Insurance B plan, will not in fact cover the birth, since the baby is the dependant of a dependant. She would have been covered under the Insurance A plan, and Insurance Company B itself even said they would cover it, but according to dad's company, as of April 1, "we don't do that anymore." The baby has been on Tara's husband's insurance (Insurance Company K) since birth, but Company K covers very little at Hospital AB, where Tara was forced to deliver.

Tara and her husband do not have the means to pay for the birth, and they're not sure how this all happened.

Question: what could Tara have legitimately done differently? What can she do now?

Story #2:
A man calls Hospital K and finds out he has an outstanding balance of several thousand dollars. The billing agent asks, "Would you like to take care of that now?" The man expresses surprise at the amount, as it seems well in excess of his out-of-pocket maximum.

"But this says you were uninsured," the agent says.

"No, in fact, we're insured with you -- with Insurance Company K."

"Oh," says the agent. With almost no effort, he pulls up the correct account.

Some time later, the man receives a much smaller bill, which he pays immediately. He is never issued an itemized statement, however, despite his having asked upward of four times for such a document over the course of two months. If the receipt is not received and faxed to the debit card provider soon as proof of an eligible medical expense, the payment will be rendered null, the card will be disabled, and the bill will likely be sent to collections.

Question: Is this also an indication of our broken system, or is it simply that the people who process billing at health care providers are broken? How many people end up paying more than they should?

Story #3:
A man -- Josh, perhaps -- and his wife receive a call from a collections agency regarding thousands of dollars in unpaid medical bills at Health Provider AB from more than a year before. They're confused. This is the first they've heard of any such charges, and in fact, they don't even make sense. Josh's wife is listed as the patient, but she received no medical care during the specified time period.

Josh makes a call to the collections agent, who is just as confused as he. She can't figure out what the charges are or why they weren't covered by their insurance. Josh makes several calls to Provider AB, and is given different answers each time. None of them seem to believe Josh's story -- that his wife never received any such care. On the third or fourth call, a Provider AB billing agent tells yet another story, that the charges are not, in fact, for Josh's wife, but for his son. The agent says the charges are so high because Josh's son was uninsured.

Josh knows that his son was on the state's Medicaid program at the time, and that Provider AB had billed it correctly on several other occasions. But at the time of these phone calls, Josh no longer has his son's Medicaid card, as that account has been inactive for almost a year. Josh spends hours and days on hold with the state's Medicaid program, which actually usually ends up with him being transferred to phone numbers that don't work, and therefore simply hang up on him. When he is able to speak to a human, the human often tells him that Medicaid numbers can not be released over the phone. He orders a Medicaid verification letter to be delivered to his house. A month passes, and it never comes. He spends more hours and days on hold, and then once, for no apparent reason, a human is more than happy to give him his son's Medicaid number.

Josh gives the number to Provider AB, who says they'll work on reversing the bogus charges. The outcome remains to be seen.

Question: WTF?

Responses will be accepted in the comments section, though aggressively partisan arguments risk deletion. These problems (especially as expressed in Story #1) are at once nobody's and everybody's fault. I'm not sure if dealing with them feels more like the eastern hemisphere, the past, or fiction. It could be Dickens's Circumlocution Office, which I guess is technically all three. Anyway, for the first time ever, I think I've actually lost all faith in an American institution, and that makes me sad.

*The names have been changed so as to not make it sound like I'm just whining, though I suppose I am. I'm honestly just more blown away by the failure of the system than anything. If you hadn't figured it out (Josh and Tara -- come on), each of these stories is about us. This may be the first time that sheer exasperation has driven me to blogging, which goes to show just how out of ideas I am.

1 responses:

SnapHealth said...


This is the problem with using health insurance to pay your bills - every insurer is trying to get out of it and it makes for a very complex system that is very difficult to understand and just as importantly - is very expensive.

Remember - those claims agents are all getting paid - mostly to try not to see who else should pay the bill - who's paying them? You! Your health insurance premiums go directly towards paying people at the insurance company to see who else should foot the bill. Does that make any sense to you?

If healthcare were made simpler, where regular care was paid by the individual and catastrophic major life events were backed by insurance, the system could be made much simpler. A much more logical plan would be an indemnity plan that pays you back or sends you a check for something like childbirth - that way you know exactly what you're getting and then you, as the consumer, now have strong incentive to shop around to get the most value for the money.

This would force transparency in pricing from healthcare providers and facilities so that the individual consumer can make good value-based decisions.


The whole system is broken - the process over decades has become so perverse so that retail rates and what insurers pay have completely gone out of whack. Often, insurers are paying only a small fraction of what is billed, but the unwitting average person gets the retail rate, feeling powerless.

The uninsured actually has the ability to call the hospital or facility and negotiate it down but that's a lot of work. Imagine if you went to go buy a car - the retail rate is $100,000 for a small four door sedan. If insurance buys it, they pay $8,000. But the price offered to you is the full $100,000. That's how healthcare pricing works today. Does this make any sense to you?


Even with government assistance programs like Medicaid, consumers need to have skin in the game and have a reason to make value-based decisions. What would make more sense would be a health debit card for patients to spend at any healthcare facility -- with a set amount -- that way they have an incentive to shop around and make smart choices because the card will run out -- but then the system would be transparent to them - they would know how much is left on their card and know what things cost -- use less expensive sources of care like primary care and urgent care rather than visits to the ER for minor medical issues.

But the current system which is basically having a cumbersome system pay the bills for you not only is a disincentive to value based purchasing, but also is cumbersome and painful.