HEALTH CARE/Joan Retsinas

Negotiating for Survival

HMOs just threw a sop to the angry public. An industry honcho offered to eliminate pre-existing condition exclusions. (Insurers Ease Stance on Pre-Existing Conditions,” Robert Pear, New York Times, March 24, 2009). Those Monty Pythonesque provisions let an insurer cover everything but what ails you, if you had that ailment before you signed up for the HMO ’R Us. For instance, if you have had diabetes for years, a new insurer can refuse to cover insulin, or treatment for diabetes-related complications. The exclusionary period can range from 6 months to longer than a year.

Before 1996, each time a person switched insurers he ran into the “pre-existing” codicil; federal legislation now forces protection for people who are continuously covered. If an enrollee goes from insurer A to insurer B, with no time-gaps, the new insurer cannot invoke the “pre-existing exclusion.” Still, a lot of people, especially unemployed people who find themselves uninsured, have stumbled into this abyss.

The HMOs deserve applause for offering to shelve this bete noire. But this was not a one-way offer.

In return, the industry wants the government to mandate that all citizens sign up for a private HMO, with no Medicare-type government insurer standing in the wings. And the HMOs want the government to subsidize premiums for citizens who cannot pay the full tab. This is government-subsidized private insurance.

For private insurers, the dreaded specter is National Health Insurance–or Medicare for everybody, young and old. Now that Uncle Sam has marched into the banking and automotive arenas, he may well march forcefully into health care. This is a natural arena for government intrusion.

So the HMO industry wants to negotiate. Pre-existing condition exemptions enhance insurers’ profits, but today’s insurers are focusing on survival. Like banks and auto makers, insurers fear a governmental sword of Damocles hanging overhead.

Let me suggest more concessions before I, part of the angry public, support their preservation.

First, rewrite your packages. Along with pre-existing exclusions, eliminate caps. Those $25,000 caps (some policies’ caps go lower) render “insurance” an illusive shell-game. If necessary, arrange with Uncle Sam for secondary insurance to cover truly catastrophic expenses. Similarly, shelve those varied “product lines” that leave enrollees uncertain what they’ve gotten. Take your rhetoric about preventive care seriously: cover everything that people should get, but may well decline if they must pay; e.g., mammograms, shingles vaccines, colonoscopies. Enlarge networks to include all qualified physicians. You can exclude providers on the basis of competence, but not on economic criteria. Too-restrictive networks have forced patients to pay exorbitant out-of-pocket fees, or to leave trusted physicians. Cover rehabilitation. We will all eventually need it.

Second, broaden your constituency. In this new order, you must answer to patients and taxpayers as well. Put enrollees and government representatives on your boards. Add them to your boards of directors. In annual reports, include health-data: number of people immunized, number of claims denied, mortality and morbidity statistics.

Finally, lower compensation to the level of federal employees. The CEO should make no more than the President of the US. Pay the people who provide the care–hospitals, physicians, outpatient centers–quickly and fairly. Primary care physicians are the linch-pin of the system: the medical “home” for patients, the first place they go when sick. The country faces a shortage of those physicians. Raise reimbursement enough to attract enough of these linch-pins to make the system work.

If the public is going to subsidize private-sector insurers, these are reasonable concessions. If not, let government’s sword of Damocles fall.

Joan Retsinas writes about health care in Providence, R.I. Email

From The Progressive Populist, May 15, 2009

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