On another note: Congress has failed us. I demand my share of their benefits. They work for me, right?

Having worked in the insurance industry for nearly two decades, I know more than the average person. I understand underwriting, guaranteed issue, deductibles, risk, etc. I’m still learning daily and yet health insurance still makes no sense to me.

What has me floored at this point is how coverage decisions are actually made.

The Affordable Care Act (ACA or Obamacare or PPACA) is a beautiful thing, in my opinion. It will ensure healthcare for everyone. Yes, there are issues. No, it’s not perfect, but it will be better than what we currently have.

In our country currently, we have the following:

  • Doctors are dropping out of their practice entirely because it is no longer economical for them to continue. They have to carry so much insurance that they don’t make the profit we assume they do. The general public is so lawsuit happy that doctors have to make sure they will be covered in the event of ANY possible incident. Add to it all of the insurance regulations they have to follow in order to give anyone care, how can any physician keep it straight? They have to hire a full staff in order to complete the mounds of paperwork necessary for little Billy to get a required immunization so he can return to school, the paperwork so Billy’s parents won’t be charged the entire amount for the shot, the paperwork so the physician gets paid for administering the shot and all necessary documentation beyond that. Additionally, doctors have to keep their staff on point with everything and updated on all new protocols… how can doctors practice medicine anymore?
  • I’ll try to avoid talking about how athletes get paid millions for working out while doctors make pennies comparatively. Which is more valuable to our society – health or entertainment?
  • The poor who can’t afford insurance can, in some instances get some coverage or pay on a sliding scale. But not all doctors will accept this. (See the first bullet.)
  • ACA has made provisions for people with pre-existing conditions, but… guess what? It’s currently out of funding. So, anyone with a pre-existing condition (like me) is out of luck until they have no insurance for more than 6 months and may be lucky enough to find a carrier who may then look at an application for coverage. OR will have to wait for coverage through an employer. OR wait until ACA opens up the exchanges in 2014 – IF the funding is there.
  • I’ll also try to avoid mentioning that Congress received bonuses in December 2012, but programs such as this are out of funding.

What I don’t understand about insurance is this – denying someone with a pre-existing condition lowers the company’s risk of paying out for tests, treatment, etc. HOWEVER, denying that person coverage could result in such huge costs overall for the government. IF a person without insurance coverage gets ill, and cannot work, they may have to rely on government assistance temporarily via disability. God forbid, they then lose their job and have to rely 100% on government assistance – unemployment, food stamps and healthcare – for an unknown time. If that person was provided with coverage – and could pay for it – to begin with, it actually reduces overall risk. Healthy people are more productive.

I’m truly failing to understand how the system works.

Who makes the decisions from an office several states away that your doctor’s diagnosis and prescription isn’t correct? Who knows you better – the person behind the computer screen denying your prescribed protocol or the doctor in front of your face?

I lost insurance due to my divorce. COBRA was a ridiculous nearly $600 per month, so I didn’t enroll. Due to a condition I’ve had since birth, I’m now denied insurance coverage. I earn enough to pay for it, yet no one will “allow me” to have it. My employer doesn’t provide it, so I have to go without the medication I need to prevent migraines. Without my migraine preventatives I’m less productive. It’s a ridiculous cycle. I have a check in hand, but no one wants my money in exchange for insurance coverage. If I were poor or unemployed, I’d have coverage. (I’m happy someone has it at least.) Yet, check in hand, I can’t get it. I have to work through my pain the best I can and pray that I will get coverage somehow. Three more months to go before I can apply to the last company that may actually cover me – if I’m lucky. Otherwise, I’m completely out of luck unless I can find a job that pays me what I’m making now. In this economy that is not likely.

If someone can explain this mess, I’d love to understand it. As I see it and have analyzed it 10 different ways, I see no logic.

Our government should be ashamed. This is just another way it has failed the people for whom it works. I’m glad Congress has robust benefits. Maybe they should share with the rest of us until ACA is up and running. Honestly, since they are my employees, I demand that they do.


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