In Defense of 'Obama-care'

Health Insurance Hurdles

Years ago I visited a woman who'd been admitted to the hospital for a hysterectomy and a related surgical procedure. Days earlier, she'd done all the necessary pre-ops - blood draws, chest x-ray, insurance clearances and admission forms.

At 5:30 a.m. the day of surgery her husband took her to the hospital and she was admitted. About 7:15, gowned and IV'd, she was visited by her surgeon, who told her the operations were cancelled. Why? Because her insurance company had decided not to cover the second procedure after all, even though both surgeries had been pre-approved.

The result? She was discharged, had to wait three weeks until an appeal was finalized and the second procedure was approved again after all, then went through pre-op tests and application procedures once more, had the twin surgeries and was billed for her share of both admissions! That's how insurance companies control the U.S. health care system.

It would be years later when I encountered those same controls myself. In 2005 I needed surgery for a hernia on my left side. Though I told the surgeon in advance (and again the morning of my operation, as well as nurses on duty that day) that I get sick on anesthetics (unable to stop vomiting), everyone assured me that preventive measures would be taken and I would be fine.

Following the operation, I got sick in recovery and remained sick for more than two hours. After that, my wife drove me back to our hotel so I could rest. About five o'clock we went downstairs to a restaurant, since I was weak but hungry. I ordered chicken noodle soup and took one Oxycontin pill (rather than the two prescribed).

Twenty minutes later I was throwing up - and kept on until early the next morning. Calls to the hospital and surgeon's office garnered the advice to 'tough it out' and then go to the ER if I didn't get better by ten a.m. I didn't improve, so off to the ER we went. Three and a half hours later and two IV's of medication, I was well enough to travel the 90 miles back home - where an additional bill of more than $400 eventually arrived.

Two years later, almost to the day, I developed a hernia on the other side. After the surgeon examined me and confirmed that I did need another operation I said to her, "Two years ago I got deathly sick on the anesthetic and ended up in the ER. This time I'm going to be admitted to the hospital for surgery."

She looked at me and said, "No, you aren't." When I asked why not, she said, "Because your insurance company says this is an out-patient procedure and they won't pay for any in-hospital charges." I protested, saying I'd rather see the money for an ER visit spent on a room, even if I had to pay the balance myself, but she said, "No chance." So, I went to the out-patient clinic again and had to repeat the entire horror show of two years before, right down to paying similar charges for another visit to the ER!

Then, last fall (2010) our family doctor prescribed a new low-dose medication for me. The prescription was for one pill a day for 90 days, with three refills. When the pills arrived, however, there were only eighteen of them - with three refills. I phoned the mail-order pharmacy and asked why the number of pills had been reduced and got this answer: it's a medication that requires pre-approval (though we were never told that).

So I asked, "How do I get them approved?" They told me to have my doctor send a letter to an office address they provided, saying that she was requesting prior approval of the drug. I passed on that information to my doctor's office and several weeks later received a call from the doctor's office assistant, who told me the request was denied because I had never tried an even smaller dosage of the same medicine.

I asked what the next step might be and was told we'd have to try the lower dosage first and have the doctor state that this was a "medical necessity." If approved and if that miniscule dosage wasn't enough, then we'd have to tread the 'pre-approval waters' all over again!

Isn't medical insurance coverage wonderful in this land that boasts of the best medical system in the world? And yet we are beset by people who lobby against a 'government-run' health care system. Well, just in case those persons haven't personally experienced a tightly controlled health care system that ignores common sense, let me assure them that we already suffer from one of those.

I say let's try a different approach - maybe enact the plan already approved by Congress, or perhaps a one-payer system after all. A family we know who live in both Germany and Switzerland are doing just fine with their health care!

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1 comment

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chefsref 5 years ago from Citra Florida

I thought the right wing stood for rugged individualism yet they do not want people to be responsible for paying for their own health insurance. Anyone without medical insurance goes to an emergency romm and we support emergency rooms through higher insurance rates and local taxes. So much for the rugged individual.

I've had experiences similar to yours where insurance found a technicality to deny care. That is the conservative Capitalist way. The best thing we can do to support the current insurance system is to die early without expensive medical care

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