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The Frustrating Thing(s) About the US Health Insurance Marketplace - Part 1

Let's be clear: I'm all for people having insurance.  I spent enough time working in the US healthcare system to see what a lack of health insurance does to patients.  It adds to the stress of their illness and sends many into medically driven bankruptcy because of their medical bill debt --something no one should ever have to endure.  I was thrilled when the Affordable Care Act [ACA] (a.k.a Obamacare) passed. With my policy training, I knew the bill was far from perfect but what was important in the US context was to get it through and then embed it in the bureaucracy, as happened prior to and continues since implementation.

But there are flaws nonetheless.  These are driven by the business of medicine and how it is funded in the US.

This is the story of my friend Eva.

Eva and I did our PhDs together. Instead of going into academia, she ended up in the corporate world with a good paying job and excellent benefits.  After putting in her time in that sector, she decided she wanted to make a change and work in the non-profit world.  Because of the ACA, she was actually able to make a major career change.  She'd planned to leave her job for six months, saved up money to live off of while she transitioned, and as soon as she left her old job she signed up for health insurance through the ACA generated exchange.  Yes, she could have signed up for COBRA but it is expensive, as anyone who's had it will tell you, so the ACA was a more affordable option. It gave her a few extra months for her career transition.  Her sign up process wasn't too bad, she told me, and she got a plan she liked and felt she could afford.

Now here comes the part you were probably expecting.  The other day Eva got a bad cold that included laryngitis. She first went to an urgent care clinic and they didn't take her insurance (even though her insurance company website said they did).  So she paid for the visit out of pocket because she had a big interview coming up and at least wanted to be able to talk.

She had the interview and the next day gets worse. We meet up for breakfast (to rehash the interview of course) and I realize she needs to be seen by somebody.  Since she's not currently based in New York but planning to be, she doesn't have a primary care provider (PCP).  I refer her to mine.

She calls my PCP's office. First, she's told there are no appointments until two days later and none til Friday for new patients.  I declare this unacceptable and get on the phone.  I play the card of being both a patient in the practice and a nurse. The latter generally assures the person answering the phone that this is not a hysterical hypochondriacal phone call that many who work in primary care manage. After the admin person relays the story to the docs, they agree to arrange for someone to see her --and that's one reason why I like the practice so much.

A triumph of system work arounds!  I'm psyched she can get seen.

Then they ask what insurance she has and Eva tells them.  Turns out, they don't take it for what are likely financially driven reasons around the amount they get reimbursed for services or the amount of paperwork hassle involved with getting reimbursement from private insurance.  This is a common practice among many primary care groups in the US.

#systemfail number 1

To be continued....


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