The next section discusses minimum standards that any reform (or any American healthcare system) should meet, implying that our current system lacks such standards:
- Affordable Coverage
- Essential Benefits
- Consumer Protection
“A qualified health benefits plan may not impose any pre-existing condition exclusion (as defined in section 2701(b)(1)(A) of the Public Health Service Act) or otherwise impose any limit or condition on the coverage under the plan with respect to an individual or dependent based on any health status-related factors (as defined in section 2791(d)(9) of the Public Health Service Act) in relation to the individual or dependent.”
Pre-existing conditions. This is a bane for insurance companies and would be a boon for the consumer if it were stricken from our vocabulary. Since this is a complicated topic and can get tedious in the usual setting, let me try to break it down by applying this principle to a problem we are all much more familiar with: Say you are an enterprising young woman (or man) and you just moved to Anytown, USA, eager to resume your career as an escort or gigolo. You approach a casually dressed pimp on the street and suggest a business partnership – he (or she) provides you protection, tight clothes, and cocaine and you perform sexual acts for money. The potential pimp asks you about your preferences and you are quick to mention that, as a result of a catastrophic gerbil-meets-rectum celebrity party you participated in many years ago, you sustained permanent anal damage and are exclusively an ‘exit-only’ kind of escort. The pimp quickly denies covering for your street protection, citing this pre-existing defect in your skillset. You plead with him, explaining that you had no choice, it was completely out of your control, and you have been struggling with the consequences ever since and only wish you could have this problem be addressed. He threatens to choke you and you leave, approaching another pimp and receiving a similar response. And another, and another. And before you know it, you’re alone on the streets, bleeding out your butt and crouched in a naked ball begging for some breathmints, all because of an incident – that was no fault of your own - that happened to you years earlier that remains a chronic problem. Ladies and gentlemen, pre-existing conditions!
I have heard from many new clinic patients who have waited months to see a new primary care doctor (once they lost one insurance plan and then scrambled forever to find another insurance company that would actually cover them). Naturally, these tended to be middle-aged people who already had accumulated a medical problem or two, and thus kept getting denied coverage for having these problems, leaving them in a position where they could not be taken care of for the medical issues they have because of the issues they have*. In other words, barring hordes of cash that no one has anymore, the only way you can get real health care coverage is if you are already healthy and don’t need it as urgently in the first place. Meanwhile, the rest of us are subjected to lesser or no care, and pretty soon everyone is terrified of the gerbil that will seal their doom.
Interestingly, a way around this is to simply lie, as physicians have attempted to do, by hiding a patient’s health problems on the chart until the whole pre-existing conditions exclusion period is over and the patient magically develops hypertension, diabetes, and heart disease overnight. Unfortunately, insurance companies figured this out (presumably as a result of disappointing profit margins) – my health insurance company, Blue Cross PPO, even threatened doctors on this problem last year in a memo of remarkable douche-itude.
Given this, I thought I’d attempt an experiment and confront a random insurance company with my pre-existing condition to see if I would still be eligible for coverage. I constructed a heartfelt letter explaining my condition, hoping that it would not bar me from getting access to medical care. However, I have not yet received a reply. My problem? I have a superfluous third nipple. I bet you thought I was going to say something about my butt.
*For any computer science geeks out there (don’t be shy, everyone already knows you are a loser), it’s sort of like a logic error in your code leading to an infinite loop, but instead of the loop just screwing up your crappy attempt at an iPhone app, it slowly makes you blind, shuts down your kidneys, and kills you. I should add that I might be totally wrong on that. I should also add that I first dabbled in computer programming in 6th grade, making an Apple IIC to print “Fuck you!” forever (I almost got suspended for that one). Look at me now, Temple Emanuel Day School!