Many of the children who grew up intoning the Nancy Reagan Just Say No mantra now work in the health-care industry. Those years of saying no trained the tykes for todays jobs.
Utilization-reviewer/denier. These people say no to the expensive procedures that might save, or prolong your life. Imagine the scenario. You go to your physician with a persistent ache. You try an inexpensive treatment. It doesnt work. The ache worsens. The ache may be, literally, a killer. Your doctor suggests a treatment that might work maybe an organ transplant. In medicine, there are few guarantees. Might is all the doctor can promise. But you are willing to endure months of painful misery. Your insurer, though, isnt willing to endure the expense. A reviewer says no to the procedure. You can, of course, appeal. Most appeals will succeed providing you live long enough. Post-mortem tort lawsuits that enrich your family wont help you.
Insurance-denier. Health-care has a caste: the uninsurables. These people have the chronic and acute illnesses that translate into mega-tabs. So insurers take the only rationale course when confronted with would-be enrollees who are sick: insurers say no. The Commonwealth Fund estimates that 89% of the applicants for individual coverage (not linked to an employer) hear no.
Indeed, healthy insured people occasionally get sick. Insurers can even say no to them retroactively denying coverage. In a recent California case, Blue Shield denied an enrollee coverage when his post-accident tab hit $450,000 and billed him $100,000. Also in California, Blue Cross has been accused of going through its claims data to deny coverage to individual enrollees when their expenses hit an unacceptably high level. The insurers can argue that the enrollees mis-represented their status on their applications; the enrollees, that the mistakes were in good faith, the result of confusing bureaucratese. The legality of this after-the-fact medical underwriting is being debated.
Pre-existing condition sleuth. When a new enrollee signs onto an insurance policy (assuming the person has never been insured), insurers rule out coverage for pre-existing conditions. So if the new enrollee has asthma, cancer, Parkinsons whatever the malady- the insurance will cover treatments for every other malady, not the one that afflicts the enrollee. The black-out period can last as long as a year. Sleuths pore over claims, to verify that the treatment is not for the pre-existing malady. If so, the insurer says no.
Corporate retirement officer. The federal Equal Employment Opportunities Commission recently gave employers a green light to say no to older retirees who expect corporate health benefits. No penalty paid. No warning needed. This is just say no time for the people getting gold watches. Cash-strapped companies want to bifurcate retirees: those over age 65, who are entitled to Medicare anyway by virtue of age, will get nothing from their erstwhile employer. Younger retirees will get coverage. The companies have wanted this age-65 cutoff: with a limited pot, the company would struggle to pay the insurance for everybody. This strategy lets them focus on the younger retirees, who have no other recourse. Ultimately, a company that couldnt foot the bill for all retirees might nix the benefit entirely. That at least was the fear of groups that cheered the EEOC ruling. From a corporate vantage, the strategy is rationale.
Health care depends on nay-sayers. Funded largely by private-sector employers, premiums rise and fall according to expenses. Experience-rating, which divides the private sector into millions of separate workplaces, puts smaller corporate entities at a distinct disadvantage. Depending on the size of the pool, a catastrophic expense can drive up premiums sometimes forcing a company to cut back benefits, if not to drop insurance. And health care follows a corporate model. It is a private-sector enterprise whose salaries match the mega-salaries of all private-sector honchos. Many health care companies are publicly traded. The just say no-ers are essential: they keep costs down and profits up.
Ironically, the bigwigs corporate and governmental most supportive of nay-sayers will never hear no. Nobody is likely to deny them coverage, much less deny them treatment.
Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email firstname.lastname@example.org.
From The Progressive Populist, February 1, 2008
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