Before I get into the whole topic here, I should mention that this isn’t about being against ACA/Obamacare, Healthcare in general, or anything of that sort. It’s just a story about a broken system.

When I first read into the healthcare system in the US, I was pretty taken aback by some of the horror stories: health insurances refusing to pay for life-saving procedures, people getting massive bills for simple procedures, and overall, getting fucked over (excuse my language). But, every system has horror stories. Socialized medicine often gets crap for having long queues, poor management, and so on.

The problem with horror stories is the extreme. And I want to talk about the “norm”. In particular, I want to talk about the norm of those around me which means I only have anecdotal experience that seems to be pretty damned consistent.

For a little background, (but as not to reveal my identity), I’ll just tell you that I’m middle-class, I’m a developer, and I have a family that I take care of.

Startups and Healthcare

When getting into a startup, you wouldn’t expect healthcare…unless you were promised it. What a lot of business owners don’t realize is that it’s not that simple. I’ve gone through three separate startups that tried to cover their employees but failed to do so. Why? Size.

First, the ACA doesn’t require small business owners to require coverage. I think that’s fine. If a company is less than 5 people, it totally makes sense to not require coverage. It’d be ridiculous and would topple startups in a second.

Second, insurance companies make startup healthcare impossible either due to cost or specific rules that they carry.

When I join a startup and hear “We’ll provide a healthcare”, I immediately know that they’re a young startup and they haven’t gone through the hell that I’ve seen other business-owners go through.

I was lucky enough to be placed in a position to get paid enough to pay for healthcare out of pocket. I’m not a huge proponent of it but at least I can stay away from paying fines.

Healthcare is actually pretty expensive even on a smaller scale. About $500 will net you a “bronze” level or worse for a couple. This means that you basically get no benefits and a “high deductible”.

The word “deductible” bothers me here because it doesn’t really reveal what it actually means. So let me explain it in layman’s terms:

> A deductible is an amount of money you have to burn through before your health insurance actually kicks in barring any legal obligations.

At $500, you’re looking at $5K-$6K for a couple. Phew, wow.

Insurance doesn’t cover itself

Okay, so now that you have coverage, you think you’re good right? Something happens and your insurance covers you fully after your ridiculously high deductible?

Not exactly. When my wife gave birth at the hospital, we went directly to our provider’s hospital. I’m not talking about “in network”, I’m talking about a hospital branded with your insurance company. Our insurance, it turns out, has its own clinics and doctors.

We thought “Perfect!” because then there wouldn’t be any misunderstandings. I mean how much more “in network” can you be than being at your insurance’s hospital?

After the birth, we got our bill. Our insurance company charged us the appropriate amount, we setup a payment plan and thought that everything was done.

Except that it wasn’t. We got a second bill from the hospital that informed us that our insurance refused to cover several standard procedures.

You heard it right. We’re not the first to experience this and actually, this wasn’t the last time we experienced it either.

Our insurance outright refused to pay…itself. When we questioned them about it, they basically said that the doctors (their doctors) did a few things, gave us a few drugs, and whatever else that they did not cover.

In some bizaro Kafka-esque world, we were dealing with an insurance that was supposed to cover a 100% of the birth (minus deductible and like 20% of the procedure) and did not because it did not agree with the procedures its own doctors performed.

At this point, we’re not dealing with small continuous cuts (like a very healthy insurance premium). We’re dealing with a deep cut that ended up being more than the insurance company charged us itself.

> We paid the insurance’s hospital more money than we paid the insurance itself

There was no appeal to it. As you can imagine, the two are technically “separate legal entities” despite the same branding and name. And so they can disagree and charge us extra.

Appeals are rough and nearly impossible

A few months ago, my wife and I went to the doctor for a routine procedure. It involved a bit of radiology which the doctor assured me it was covered. We double-checked and called our insurance directly to discuss it. It was an “extra” procedure we didn’t necessarily need but should it be covered, we were going to go ahead and take advantage of it

After a brief discussion, the operator assured us our plan requires only a copay. We scheduled an appointment, got there, got yet another confirmation that we were fully covered. Happy that our insurance is *finally* paying off, we went it, did our thing, and went home.

You can see where this is going.

We got a bill. For the entire thing. They didn’t even subtract our copay. We called in and they basically said that we were making all of those “confirmations” up. And that there is no way they would have or will cover it.

After about an hour of arguing back and forth, we filed a formal appeal.

Weeks later, we got a response from the insurance stating that we were responsible for knowing what’s covered and what is not. A representative is not responsible for it, the doctor isn’t, the nurse, nor the receptionist.

The appeal got us nowhere other than the insurance company blaming us for using their facilities, their doctors, and listening to their representatives.

Where do we even go from here?

I should note that as an insured individual, you are liable to pay the insurance and then file for an appeal. So we had to pay, and then we got a letter telling us they denied us.

Let’s talk about “the Network”

One of the worst inventions of American healthcare system is the “Network” system. The “Network” is basically a sprawling registry of doctors that you are allowed to see that your health insurance will cover. Those doctors have to fulfill certain criteria and the insurance has to approve them.

Not only does this cost doctors a good deal of money but because of it, doctors aren’t able to keep covered under all forms of health insurance.

A year ago, I had to go see a specialist that my health insurance didn’t have in their network. It was literally the only person in a hundred mile radius that was able to help. Sounds unbelievable but not uncommon (anecdotal knowledge).

I tried to get my health insurance to cover him especially after the “covered” doctors couldn’t help and even recommended this specialist. I filed for a “referral” to go outside of the network and while my insurance-specific doctor approved the referral, the insurance didn’t and told me to go see their doctors again.

I ended up paying out of pocket and killing my budget for several months to come.

When I looked for a pediatrician for my kids, I experienced the same issue. I didn’t need a specialist but I wanted a doctor that I would feel comfortable around. I did find several but all were out of network. Referrals didn’t matter. After some arguing with an associate at the insurance company, they finally broke down and told me the truth:

Referrals rarely ever get approved. I’ve only seen it happen once or twice in the entire time I’ve worked here. You will most likely have to pay out of pocket.

Rising costs cost us health

The phrase “health benefits” just rubs me the wrong way. It makes insurance sound like a luxury. It makes health sound like a luxury! But there it is. Being able to afford healthcare is easy when you’re healthy but the second you get sick, it can bankrupt a person.

There’s a pretty famous story about Joe Biden unable to afford his son’s cancer treatment while he was VP. How do you think the average person deals with this kind of thing?

My health insurance has steadily gone up for the past two years. Sometimes it crawled, sometimes it leaped. From 2015 to 2016, my insurance was going to go up from $500/month to $600/month with less benefits. I had to downgrade to a lesser plan for $500 in order to afford it. From 2016–2017, my health insurance wanted to go up from $500 to $650. With no change in benefits.

I had to downgrade once again and this time, it cost me. I lost my therapy coverage. I’ve been struggling with depression, anxiety, and other sorts of problems. I’d love to get into a “why” but I’ll leave that for another post.

> The new downgrade meant that I could no longer get the help I needed.

I’ve been skipping my appointments for a couple of months now, going only once or twice. It’s been hell. It has had a horrendous effect on my personal life, on my work life, on my wife. On everything around me.

My last therapy session, my therapist offered to slash my rate in half. It’s still two times the original co-pay I used to pay but at least now, I can afford to go more often. Therapists aren’t expensive, but this stuff adds up.

My mental health became a “luxury”. I’m not the worst-off person out there but I can’t imagine someone who needs medication or is at a threat to themselves or possibly others, not being able to get the help they need.

Is there a solution?

I’m not sure. Getting rid of ACA is definitely not it. I have a pre-existing condition that would disqualify me from coverage. I haven’t lived long-enough in Europe to know how well their insurance goes.

I do remember being covered for all kinds of things, being able to go to an ER when I broke my foot without worrying about the cost. But I’m not the best person to ask about that.