The State of Public Health Care in the United States

The only way I can tell this story is to share the personal experience of someone I know very well. I can't pretend to be unemotional about any of this. I'm very emotional about healthcare.

I'm 56 years old, and I grew up in the days before such company-oriented niceties as coordination of benefits and “managed” health care. We got sick, we went to a doctor, and our employers (or our parents' employers) provided the health insurance that took care of it.

Not having “coordination of benefits” meant that if you had coverage from two companies, both paid. Maybe that is seen now as unfair to the insurance companies, but all it really meant was that each company had to pay what they had contracted to provide, without coordinating with each other to make sure that you didn't get more than they wanted to pay you.

It's common enough to have more than one life insurance policy, and we'd be shocked if the various insurers got together to decide how much they should pay your survivors in order to minimize their own responsibilities. We'd be shocked, horrified, and they'd be sued. And they would lose, because each has contracted to insure your life for a certain amount of money. But we take it for granted that health insurance carriers have the right to decide amongst themselves just what our benefits will be.

I know someone who was employed for most of her adult life. That's meant that she'd had company provided health care for most of her adult life. In fact, one of her jobs was as a referral and authorization coordinator for a major managed health care company.

It was her job to look at your file and make basic decisions on what health care you were entitled to receive. These were basic decisions, usually involving a “rule out” diagnosis and two visits to a specialist. There were always certain conditions that had to be met, and if they weren't, the case was sent to a nurse for review. Anything beyond the nurses was reviewed by a doctor. The nurses fought for some cases, and some of the fights were lost.

Nurses would end up in tears because a patient they had never met had been refused treatment and had died. I'm not qualified to imply cause and effect here, though it's tempting. These patients might have received the requested treatment and still died. That's the reality of medicine in the real world.

Instead, I would say that these were sound business decisions, made by an organization designed to be for profit. I would also have to tell you that while she was working for the company, their CEO was second in this country only to Michael Eisner in salary and perks. Michael Eisner was running Disney, an entertainment company. The medical insurance company CEO was running a business that had responsibility for safeguarding people's lives.

She moved on from that company, but not before being diagnosed with heart problems and what would later turn out to be fibromyalgia. A couple of years later, she married and left the work force to care for her new husband, who was partially disabled and needed her help in order to be able to work full time.

Her new husband's employer provided them with health coverage. It was HMO care, and they sometimes spent half a day sitting in a waiting room, but at least they had care from doctors and pharmacists they respected and could communicate with. Of course she didn't have a cardiologist for most of that time, because the HMO didn't include a cardiologist that her PCP (primary care physician) trusted. Ditto for a dermatologist. Ditto for a podiatrist. And the same for an orthopedic surgeon and a psychiatrist. And no neurologist or endocrinologist for her husband. Still, their overworked PCP's managed to keep their conditions under control.

Eventually, her husband's job went south, and so did their health care. And then, so did her marriage. She ended up moving back in with her parents at the age of 50, with no health and no health coverage. She was unable to get out of bed for the first month she was there. It took her 6 months to track down the county version of the health care she needed. This is what is known generically as Medicaid, although it has different names in every state and/or county. We both find it hysterically funny that in her county she's considered a medically indigent adult, or MIA.

Medicaid is paid for by the federal government, but administered by the states and counties. She had good documentation for her conditions, in part because she was already halfway through the process of applying for Social Security disability. So, it only took her about 4 months to get back on the meds she needed. The meds that one of her former physicians had described as, “…the ones that keep you alive, and the ones that keep you taking the first ones.”