The Progressive Populist
Mike Madden noted at Salon.com (8/10) that US health care already has “death panels,” but they’re run by private insurance companies that determine who gets medical coverage. In one notorious case, CIGNA denied a liver transplant for a 17-year-old California girl suffering from leukemia in 2007, despite the recommendation of Nataline Sarkisyan’s doctors who said she had a 65% chance of succeeding. The company decided that wasn’t a good enough reason to order the transplant. The bureaucrats held their ground for a critical 10 days before they relented, just two hours before the girl died in December 2007.
The American Medical Association reported that the biggest insurance companies in the country denied between 2% and 5% of claims put in by doctors last year. There is no national database of insurance claim denials, because private insurance companies aren’t required to disclose such stats, Madden reported. A House Energy and Commerce Committee report in June found that three insurance companies kicked at least 20,000 people off their rolls between 2003 and 2007 for such reasons as typos on their application paperwork, a pre-existing condition or a family member’s medical history. The insurance companies saved $300 mln. Many clients were denied insurance after they put in claims. People who buy insurance under individual policies, about 6% of adults, are especially vulnerable, but the 63% of adults covered by employer-provided insurance aren’t immune to difficulty, Madden noted.
Some other healthcare horror stories Salon.com turned up from the current system:
• In June 2008, Robin Beaton, a retired nurse from Waxahachie, Texas, found out she had breast cancer and needed a double mastectomy. Two days before her surgery, her insurance company, Blue Cross, flagged her chart and told the hospital they wouldn’t allow the procedure to go forward until they finished an examination of five years of her medical history — which could take three months. It turned out that a month before the cancer diagnosis, Beaton had gone to a dermatologist for acne treatment, and Blue Cross incorrectly interpreted a word on her chart to mean that the acne was precancerous.
Not long into the investigation, the insurer canceled her policy. Beaton, they said, had listed her weight incorrectly when she bought it, and had also failed to disclose that she’d once taken medicine for a heart condition — which she hadn’t been taking at the time she filled out the application. By October, thanks to an intervention from her member of Congress, Blue Cross reinstated Beaton’s insurance coverage. But the tumor she had removed had grown 2 centimeters in the meantime, and she had to have her lymph nodes removed as well as her breasts amputated because of the delay.
• In October 2008, Michael Napientak, a doorman from Clarendon Hills, Ill., went to the hospital for surgery to relieve agonizing back pain. His wife’s employer’s insurance provider, a subsidiary of UnitedHealthCare, had issued a pre-authorization for the operation. The operation went well. But in April, the insurer started sending notices that it wouldn’t pay for the surgery, after all; the family, not the insurance provider, would be on the hook for the $148,000 the hospital charged for the procedure. Pre-authorization, the insurance company explained, didn’t necessarily guarantee payment on a claim would be forthcoming. The company offered shifting explanations for why it wouldn’t pay — first, demanding proof that Napientak had tried less expensive measures to relieve his pain, and then, when he provided it, insisting that it lacked documentation for why the surgery was medically necessary. Napientak’s wife, Sandie, asked her boss to help out, but with no luck. Fortunately for the Napientaks, they were able to attract the attention of a Chicago Tribune columnist before they had to figure out how to pay the six-figure bill — once the newspaper started asking questions, the insurer suddenly decided, “based on additional information submitted,” to cover the tab, after all.
• David Denney was less than a year old when he was diagnosed in 1995 with glutaric acidemia Type 1, a rare blood disorder that left him severely brain damaged and unable to eat, walk or speak without assistance. For more than a decade, Blue Cross of California — his parents’ insurance company — paid the $1,200 weekly cost to have a nurse care for him, giving him exercise and administering anti-seizure medication.
But in March 2006, Blue Cross told the Denney family their claims had exceeded the annual cost limit for his care. When they wrote back, objecting and pointing out that their annual limit was higher, the company changed its mind — about the reason for the denial. The nurse’s services weren’t medically necessary, the insurers said. His family sued, and the case went to arbitration, as their policy allowed. California taxpayers, meanwhile, got stuck with the bill — after years of paying their own premiums, the Denney family went on Medi-Cal, the state’s Medicaid system.
• Patricia Reilling opened an art gallery in Louisville, Ky., in 1987, and three years later took out an insurance policy for herself and her employees. Her insurance provider, Anthem Health Plans of Kentucky, wrote her this June, telling her it was canceling her coverage — a few days after it sent her a different letter detailing the rates to renew for another year and billing her for July.
Reilling thinks she knows the reason for the cutoff, though — she was diagnosed with breast cancer in March 2008. That kicked off a year-long battle with Anthem. First the company refused to pay for an MRI to locate the tumors, saying her family medical history didn’t indicate she was likely to have cancer. Eventually, it approved the MRI, but only after she’d undergone an additional, painful biopsy. Her doctor removed both of her breasts in April 2008. In December, she went in for reconstructive plastic surgery — and contracted a case of MRSA, an invasive infection. In January of this year, Reilling underwent two more surgeries to deal with the MRSA infection, and she’s likely to require another operation to help fix all the damage. The monthly bill for her prescription medicines — which she says are mostly generics — is $2,000; the doctors treating her for the MRSA infection want $280 for each appointment, now that she’s lost her insurance coverage. When she appealed the decision to cancel her policy, asking if she could keep paying the premium and continue coverage until her current course of treatment ends, the insurers wrote back with yet another denial. But they did say they hoped her health improved.
Wendell Potter, the CIGNA insurance executive turned whistleblower, told the Senate commerce committee (6/24) insurers routinely dump policyholders who are less profitable or who get sick. In addition to individual policy rescission, they also dump small businesses whose employees’ medical claims exceed what insurance underwriters expected. “All it takes is one illness or accident among employees at a small business to prompt an insurance company to hike the next year’s premiums so high that the employer has to cut benefits, shop for another carrier, or stop offering coverage altogether — leaving workers uninsured,” a practice known in the industry as “purging.” The purging of less profitable accounts through intentionally unrealistic rate increases helps explain why the number of small businesses offering coverage to their employees has fallen from 61% in 1993 to 38% today, according to the National Small Business Association. And once an insurer purges a business, Potter told the senators, there are often no other viable choices in the health insurance market because of rampant industry consolidation.
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