Health-insurance diagnosis: sick, getting sicker, and Medicare prescriptions are no cure

While Ted Kennedy and George W. Bush and so many other unlikely allies are busy congratulating each other on last week's passage of Medicare reform bills (which offer some prescription coverage to some senior citizens in some circumstances in exchange for much of their privacy), a few thousand more Americans woke up without health insurance this morning.

Of course, a few thousand people (or more) lose their health coverage every day these days, so this group's loss isn't exactly man-bites-dog breaking news. The number of uninsured goes up every time it's reported; the most recent consensus of estimates is 40 million and counting. But today's loss is a particularly hard one for me, because I know how hard the National Writers Union (Local 1981 of the United Automobile, Aerospace, and Agricultural Implement Workers of America) worked to keep its members covered.

The NWU's plan, which expired at midnight last night with no replacement coverage to be found anywhere at any price, was what they call an association-type plan, covering not a group of employees in a factory but a group of independent contractors spread over 49 of the 50 states (thanks to the laws of the state of New York, currently insured members there are still covered, though no new members can enroll).

Insurance companies have developed a severe allergy to association-type plans in recent years; meanwhile the number of people working independently continues to rise. Insurers may not like freelancers, but employers love them: no benefits, no commitment, no problem. Employers love freelancers so much that they often replace regular employees with them, or even force full-time employees to become freelancers.

It's sometimes difficult to tell which employees are real and which are freelance, as they often work side by side, 40 hours or more a week in many American businesses. In many offices there are freelancers with months or years of theoretical seniority over workers who've actually been "hired;" those and other long-term full-time freelancers are known as "permatemps."

Some independent contractors, such as myself, are fortunate enough to be included in their spouses' group coverage, so we aren't inclined to shell out another several hundred dollars a month for duplicate coverage through the association, in my case the NWU. And that fact, the insurance providers say, is why non-employer-based group plans aren't worth the bother (and risk) of collecting premiums.

I had a falling out a year or so ago with a friend of mine over health insurance: born into a wealthy family, he owns a small business founded by his grandfather. He can't understand why anybody would go without health insurance; to him it's just irresponsible not to buy it. He shops for insurance for his company, and (so far), his company has enough employees to qualify for a group plan. So he doesn't know that health insurance isn't available to every individual who offers to pay premiums. While there are individual plans available to some at a much higher cost than group coverage, they generally exclude any pre-existing conditions, and providers choose their individual customers very carefully to minimize risk and maximize profit. To paraphrase those ubiquitous Medicare-supplement TV commercials, "If you have diabetes (or other pre-existing condition), and you're a freelancer, I've got some bad news. You may not be able to buy medical insurance at any price, anywhere in this nation, or if you can, it won't cover your condition. Guess you should have thought of that before you a) got sick or injured, b) went to work for a company that doesn't offer insurance, c) lost your job and could only find freelance work, or d) any or all of the above." Nobody's going to pay Wilford Brimley to tell you that.

Of course, in these iffy economic times, my friend's company may lose an employee or two, but even if it doesn't, by the time the next round of insurance negotiations come around, his business might not be big enough anymore to interest a provider. I wouldn't wish that on anybody, but I fear that may be the only way my friend will understand why some people are uninsured.

Like my friend, our elected representatives don't have to scramble for health insurance, either: the taxpayers take care of their medical coverage. No matter how many hearings they may hold, they have no idea what it's like for the rest of us.

Being uninsured and unable to buy coverage does have a brighter side, though: people without insurance don't have to bother with the frustration of having each and every health-care claim automatically rejected by their providers. I went in for a physical last week, and have yet to receive the rejection for that, but the previous time my insurance provider rejected the bill for the associated blood tests, claiming they hadn't been authorized by my doctor even though the blood was drawn in his office by his employee on his written orders and he himself called me with the results. The insurance did pay, eventually, but not for the time or effort I had to put into appealing the rejection.

Over the past four years, our medical insurance companies (there've been five different ones) have automatically rejected nearly every claim, and firmly refused to pay for X-rays performed during surgeries they themselves had pre-authorized, claiming the X-ray provider was "out of plan." Remember that next time you go under the knife: you may need to wake yourself up during surgery to remind the doctors that your X-ray and pathology work can only be done by "in plan" radiologists and pathologists; take along that phone-book-size directory of "in-plan" providers into the operating room just to be sure. For a few months there, we were insured by a Virginia health-insurance company, which meant that although we live in New Jersey and Michael worked in New York, we couldn't go to a doctor outside the state of Virginia without special permission from the insurance company. Then there's the insurance company that insisted Michael should have left the hospital the morning after a 7-hour back operation, and insisted that we pay approximately $23,000 because his doctors wouldn't release him as the insurance company ordered. I did call them to ask how I was supposed to transport a patient with all those tubes in him, IV and morphine pump still attached, and whether they would pay for such transportation, but they have yet to respond to that question. We haven't gotten a nastygram from them in awhile, though, so maybe our appeal was finally successful. They usually don't bother to notify us when we win one.

So you folks in Washington, keep right on patting yourselves on the back. Brag about offering a few health-care crumbs to old people if they can prove they're poor enough. Swagger at the notion of making basic coverage possible for cute little children, right up to the moment they turn 18 and have to fend for themselves. But remember that people of all ages need health insurance, whether they are employed, self-employed, underemployed or unemployed. And remember that every day, thousands more find themselves without it. If you ignore them, you, too, may find yourselves self-employed and unable to buy insurance at any price.