An underinsured kick in the groin
21 01 08 - 11:11
THE NEARLY 300,000 Massachusetts residents who signed up for health insurance under the state's new initiative are in for a rude awakening. They may now have some form of coverage, but many of them, even the very poor who used to get free care, are going to be socked with steep medical bills.
more stories like thisWelcome to the shadowy world of underinsurance, where high premiums, copays, deductibles, unexpected co-insurance charges, and skimpy coverage have put the lie to the dream of health coverage for millions of Americans. According to a 2005 Kaiser Foundation study, more than 58 million Americans already find themselves in this category: underinsured and at high risk of incurring punishing medical bills. My family is among them.
On Aug. 17, my 14-year-old son was kicked in the groin during a preseason soccer match. He could barely walk and was in considerable pain, his testicles having swollen beyond proportion. The urologist at our community hospital suggested an ultrasound to make sure there was no internal damage. Since it was late on a Friday afternoon, the doctor recommended that my son go to the hospital's emergency room for the scan. The results, fortunately, were benign and my son recovered quickly.
But a month later, the bills started flooding in: hundreds of dollars from the hospital ER, plus a few hundred more from several ER doctors and the urologist who treated my son. We also owed hundreds more for other medical services my family and I had used. On top of that, we still were obligated to pay hundreds to the orthodontist for my son's braces and several hundred dollars to podiatrists for services not covered by our plan.
By last fall, we owed nearly $3,000 in medical expenses. The bills had begun accumulating shortly after my husband, a social worker, switched jobs and we were forced to change health insurance from a local Blue Cross plan to a for-profit national plan. My husband was not offered a choice of health plans, and when we signed up it was not made clear that our deductible for the year would be $3,000 (for in-network expenses; $4,500 for out-of-network expenses).
Nor did we understand that once we met the deductible (i.e., spent $3,000 to $4,500 of our own money), we would then have to pay co-insurance: 15 percent of every in-network expense we incurred and 45 percent of any out-of-network expenses. Some Massachusetts residents who sign up for health insurance under the state's new plan will face even higher premiums and deductibles. Even some low-income residents who used to get free care will have to pay co-insurance charges that they may not be able to afford, according to Physicians for a National Health Program, which advocates for single-payer national health insurance.
It wasn't until my son's injury that we began to experience what it was like to be underinsured. As the bills piled up, I could only imagine how much worse it must be for the millions of those with less health coverage or none at all.
Fortunately, we found help. After a few calls, I was directed to the Access Project (www.access project.org), a Boston nonprofit that helps people throughout the country negotiate unaffordable medical bills. Andrew Cohen, Access Project's community research coordinator, gave me advice on how to appeal our medical bills, not only with our local hospital but with our health insurer as well.
With the latter, I argued that we had already satisfied our $3,000 family deductible for 2007, having spent more than that amount in medical expenses; thus we should have been covered for some of the expenses incurred from my son's ER visit as well as any subsequent medical services.
The local hospital forgave the balance of our debt to it, while the insurer repeatedly denied our appeals. In the process, I discovered that the company, which paid its CEO more than $17 million in salary, bonuses, and stock options over the last two years, was playing a shell game with us.
Instead of counting the full amount of our medical bills toward the deductible, the company only included a lower "discounted" amount and excluded the cost of our co-insurance charges. According to the Access Project, such tactics are not that unusual. But they often go unnoticed because of the sheer complexity of the system.
This experience has taught me that our system of private health insurance is badly broken and individual states cannot institute reform alone. We need universal healthcare on a federal level and more organizations like Access Project to tide us over until we get it.
Alison Bass is a former medical writer for The Boston Globe and author of the forthcoming book, "Side Effects: A Best-selling Drug on Trial."