Giusti: Navigating the Uncivilized World of American Healthcare

​Bob Giusti

Last week, the House of Representatives -- led by the majority Republican Party (GOP) -- made good on the promise to “repeal and replace” the Affordable Care Act. You know it as Obamacare, although there are credible arguments that would suggest the ACA was flawed from the beginning due to attempts to appease the GOP into passing a very compromised and complicated plan. The Democrats paid the price for the next seven years by losing the House and Senate majority in the first midterm election.

Obamacare was mandatory but still created an exchange that depended on large insurance carriers to offer regulated plans that included no penalization for pre-existing conditions, allowed children to remain on family policies until age 26 and required mandatory coverage for prescription services as well as new Mental Health protections (e.g. no visit limits) while also offering a full regime of female health tests and procedures.

The funny thing was, Obamacare was for the Individual/Family market not covered by the large risk pool dollars of the traditional employer insurance benefit. It increased coverage for the previously uninsured and as costs rose so did premiums, co-pays and deductibles.
So, after a long death march, plus increasing pressure from the president to pass one of his key campaign promises the GOP squeezed by a plan that has not even been evaluated by the non-partisan Congressional Budget Office. Caught in the middle between 75% of constituents who favor an improvement to the existing ACA (2018 midterms are looming too) and keeping their base satisfied the result looks like a huge cut to Medicaid (over half a billion), non-mandatory coverage for pre-existing conditions and a huge tax cut (again over half a billion) while claiming that a more open market will create “greater access” to a more competitively priced market. Oh yeah, and a complete defunding of Planned Parenthood, one of the few options available to women who provide complete care above and beyond abortions at a reasonable price for the uninsured.

The House passed the hot potato to the Senate who (at press time) are inclined to rewrite the whole bill just to appease Republicans who are on the fence, let alone the Democrats who as of now are not on the panel compiled of Senators who will tweak the plan. Estimates even include stalling any new legislation until after the 2018 midterms.

Now it’s confession time.

I am a former business analyst for a large health insurance company. I held this position for about three years (customer service prior to that for four years). This was just before Obama was elected let alone the ACA. Here’s what was going on in the industry: In Rhode Island healthcare premiums for Individual non-employment plans were increasing every year by the percentages allowed through state regulations that we are lucky to have. In RI, you must except pre-existing conditions as well as 26 years to remain on the family plan.

Yet even with those guaranteed regulatory measures the cost of medicine continued to increase and was passed on to the consumer through higher copayments and deductibles as well as prior authorization as medically necessary for any procedures suggested by a specialist. 

Tort reform for malpractice was out of control causing doctors (who already had hundreds of thousands in student loans) to bleed from extraordinary high insurance payments of their own.

Hospital costs rose as new technology was required and ordinary procedure required stocked supplies were increasing in costs.

Labor for support personnel such as nurses and technicians rose as qualified employees declined.

Insurance companies became a complicated infrastructure comprised of MBA’s, Risk Management, IT improvements and regulatory compliance experts in Legal and a support staff consisting of a thousand or more making their costs rise while trying to maintain negotiated rates of payment to medical providers and facilities

Pharmacy costs rose by 600%  

Yes, folks this is just the tip of the iceberg. Trump finally said it; “Healthcare is complicated” just ask Hillary who failed and lost at healthcare (causing a Democrat loss in the first midterm of her husband’s presidency). It’s also political poison.

My suggestion? Read up on your health insurance policy. I bet you know more about your auto insurance than you do about healthcare options -- which costs you ten times more.

• Learn how your insurance works and discover the difference between “charge” and “allowance” paid on your claims. Be consumer aware.
• Understand that insurance claim computers spit out any errors as denied claims. About 40% of denials can be fixed; but each phone call to the insurer costs about $15 so know simple things like what the day of service is in advance.
• Get a yearly checkup (this especially goes out to males) to address care early when it’s not so expensive. Most insurance even waives the co-pay for you.
• Don’t go to the ER for a cold and fever. For one, you probably won’t be seen right away because you’re not in trauma and you end up costing the whole system (including yourself) unnecessary dollars. Use a walk in or call to see who is on call for your primary doctor

Healthcare is a matter of life and death, but in this country it is an out of control industry where little coordination or sharing of information has evolved since the 20th century. As a result we are the only civilized nation that does not provide universal healthcare.

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