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OT - health insurance, why its difficult to get without employment?

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Posted 11/14/2012 8:08 PM (GMT 0)
Without getting into any political controversies, I am curious to know, why here in US, it is so difficult for an individual to obtain a health insurance? DW works with a small mom and pop Physical therapy clinic with about 20 employees. The boss is very good to work with but pretty haphazard when it comes to running a business. During the storm (sandy), some delays in payments to the insurance company resulted in insurance getting termed. I realized that when I went to see my GI for a follow-up. Now it is restored but the deductible is $4000 for Rx, doctor visit and hospital visit all inclusive. Previously, it was $2000 for hospital visit only. This I learned today when i was trying to refill Rx with Medco monkeys.

I can not work for various reasons, one being my health. We considered getting insurance ourselves and its so freaking expensive. I wonder why the fcuking system is set up like this that you get health insurance only if you are employed !!! I seriously feel like go running back to Sweden... Anyways, anyone, probably someone works with insurance company has any 'easy to understand' explanation?

Again, no politics please, although it IS one of the factor.
Posted 11/14/2012 9:02 PM (GMT 0)
There are two issues, other than the fact that the system sucks and you are annoyed.

1) Insurance companies like to offer group plans because presumably most members of the group are healthy, and some administration can be centralized (e.g., once central person forwards payments and maintains roster). Workplace just happens to be a group most people fall into. (Other groups might be a professional association, or student body, ... etc.)

2) After WWII, when employers were competing for workers, they began offering group insurance plans to entice workers. It does not have to be that way, but it just sort of stuck.
Posted 11/14/2012 9:15 PM (GMT 0)
I'd say the fact that health insurance costs have been increasing year-over-year at a rate faster than that of inflation is a big factor in the current dilemma.

As the health insurance costs have skyrocketed over the past decade, younger and healthier people have opted out of getting insurance. As a result, the pool of insured people has become more and more concentrated with people who are ill, and the insurers have no choice but to raise premiums as they cannot payout more than they take in. It is a vicious circle that keeps accelerating.

A disturbing trend is the high-deductible plans that a lot of employers are starting to switch to in greater numbers. Basically, you get a insurance policy that only kicks in once you've reached a certain cap (usually a cap of few thousand dollars in healthcare costs within a calendar year) and everything else (regardless of what it is) is paid out of pocket by the employee. Luckily for us ucers a few thousand dollar cap is easily reached within a month or two of medication...
Posted 11/14/2012 9:23 PM (GMT 0)
It's freakin' expensive even on a large group plan because health care is expensive to provide, for a lot of different reasons. Your wife's employer is providing high deductible, catastrophic coverage, which is relatively affordable. You may be getting prices for "first dollar' or low deductible coverage, which is more expensive.

Insurers also charge more of individual coverage because the administrative and marketing costs are higher.

Employers actually started offering medical insurance during WWII because they weren't allowed to raise wages.
Posted 11/14/2012 10:33 PM (GMT 0)
I seriously feel like go running back to Sweden...

There are many Americans who wish they had that option.
I think you are experiencing culture shock of the differences between your home country and the US. I'm not sure it does any good to ask why they are different, they just are.

I was self-employed the majority of my adult life and therefore paid for my health insurance personally for 25+ years. It isn't difficult to purchase a policy as long as you are healthy but in 2014 insurers will have to insure people with pre-existing conditions such as yours.

My advice is to keep the insurance your wife has and deal with the high deductible as best you can and in 2014 see if you can find a better policy. But if you feel that her employer is so shaky that you can't depend on that insurance to be there when you need it then call your state insurance commissioner and ask them what your options are. Each state handles health insurance differently. They may have a website you can look at that could answer your questions better than we can.
Posted 11/14/2012 11:32 PM (GMT 0)
Something is not right in your first paragraph. If I understand it correctly you have insurance through your spouse's employer, due to the storm payments to the insurance company were not made properly causing the policy to be cancelled, and now it has been reinstated but the terms of the insurance are different now. I don't think that is legal, especially if the company's policy was truly "reinstated". Reinstated means all previous terms of the insurance remain the same. I don't think it is legal for the insurance company to terminate a policy due to "acts of god" and then give you a different policy with different terms. If that is what really happened your spouse's employer should get legal counsel and confront the insurance company. Now, it might be possible that the employer had already dropped the ball and blamed the storm for something that was actually the employer's fault, the insurance company terminated the policy, and did not reinstate the old policy but merely sold the employer a new different policy. In that case you yourself might be able to legally investigate whether the employer can do that to you or not. That theory could go one way or the other and may be decided by what is in the employee handbook or any contracts employees had with the employer regarding health insurance. One way or the other either your spouse's employer may have a legal case against the insurance company or your spouse and all of the other employees could possibly have a legal case against the employer if they so choose to investigate that possibility.
Posted 11/14/2012 11:46 PM (GMT 0)
It's very unlikely he'd have a legal case against the employer. The employer isn't required to offer health insurance at all and it's routine for the terms to change on renewal.
Posted 11/15/2012 12:08 AM (GMT 0)
I think that is my point though in regards to a possible case against the employer. Depending on wording in the handbook or any contracts the employer may have regarding health insurance with it's employees, they may not be able to change the conditions of those contracts in the middle of the policy, and, if this happened in the middle of the policy, it would be hard to argue that this was a renewal.

I am going to assume though that the employer did nothing wrong and that the storm interfered with the payment process. In that case I would think it would be illegal for the insurance company to change the terms of the policy in the middle of the policy(especially due to "an act of god", and if the policy was indeed "reinstated" then that means they are changing the terms of the policy in the middle of the policy.
Posted 11/15/2012 12:21 AM (GMT 0)
Every employee handbook I've ever seen is completely weasel worded regarding benefits - "You will be eligible for such coverage as is offered at the time", etc. They never spell out specifics like deductibles, co-pays, etc. Insurers and payroll companies offer pre-written ones to small employers that are so vague when it comes to benefits that they're unusable in court.

The state insurance commission could certainly determine if it was an unlawful termination of the plan. It's not uncommon for small employers to pay right at the last possible minute, and the payment is almost always set up as an automatic bank transfer. Maybe they didn't make the bank deposit to cover the EFT.
Posted 11/15/2012 12:59 AM (GMT 0)
Gary,

You are right in understanding. The problem here is, we are in pretty twisted situation. We are in the US ONLY because our son got a diagnosis of Autism. The services here are exceptional, although we pay a TON out of pocket, still they ARE there.

Now the reinstating part, as I said, the boss is pretty haphazard. I honestly don't know the truth. DW is not assertive to get answers from the boss. As Richard says, she is not required to offer insurance at all, so picking up a fight and spoiling work environment won't work, esp. when its a very small company. If this continues, I plan to start working next year and get insurance from my employer. At least DW's boss is very understanding when it comes to family emergencies and such accommodations but in the long run, such high deductible and no retirement benefits won't be good enough.

@imagardener2,
Yes, I agree its a culture shock and even after 2 years, I still have difficulties. I always thought moving to the US will be a piece of cake, esp. after living in many countries with the languages I do not speak. Unfortunately, the ride has been extremely bumpy in too many areas and I always made fun of US/Canadian citizens giving up their respective citizenships in favor of Swedish citizenship.
Posted 11/15/2012 1:22 AM (GMT 0)
Interesting. I've always bought my own insurance as a single-payer from Blue Cross/Blue Shield, ever since I turned 20 and wasn't eligible for medi-Cal anymore (my grandparents raised me so I was eligible for state med until 20). First I purchased through the college (UC Davis) and then when I graduated I went to the single-payer, and I've had that ever since. I always opt-out of my employer plans and ask for a stipend instead. Those are not taxed and are always enough to cover my monthly premium and then some.

If you've had continuous coverage, then pre-existing conditions are not an issue, but if you have been uninsured for 9 months or more, they can exclude preexisting conditions for up to the first 12 months, so you basically have to, say, pay cash for any UC treatments for the first 12 months, then it should be covered.

Employers don't have to cover spouses - heck, they don't have to offer coverage at all. My husband keeps only 2-5 employees, and we pay a slightly higher "cash" rate instead of offering healthcare. We can't afford the overhead and then the employees can do whatever they want with the money.

To address the "why is it so hard" question? Employers pay a TON for these plans. They have to offer equal coverage for everyone eligible - so if the boss wants 100% coverage, everyone else gets it too, but that can be almost $1000 a month! So most don't bother, or aren't big enough to get into the kind of group plans that offer a good break.

It is why I don't love the new health care bill. It doesn't do all that much to actually regulate the way insurance companies function. It regulates coverage itself, but not the industry if that makes sense.
Posted 11/15/2012 3:58 PM (GMT 0)
Health insurance is vastly misunderstood by most everyone. In fact insurance is vastly misunderstood by most everyone.

#1 and this is first and foremost the biggest reason behind the misunderstanding. Health insurance is NOT healthcare. There is HUGE difference yet people are constantly trying to intwine the two as if they were the same thing:

Healthcare is provided by doctors, nurses, hospitals etc.... These healthcare providers are, in large part, their own company(s). They have the ability to charge you whatever you negotiate with them. You DO NOT need health insurance to go see a doctor, go to a hospital or receive healthcare. This is th ebiggest misnomer in the universe. You have the ability to provate pay with all of these organizations AND you have the ability to negotiate the fee you will pay them for their service. They do not advertise this but in fact you have the RIGHT and the ABILITY to so exactly that.

Health insurance is an OPTION that health insurance companies offer to both individuals and employers to help mitigate the costs of the healthcare costs being provided by the healthcare providers. It is NOT required though. Health insurance is/was/and always will be by design a function by which LARGE GROUPS OF PEOPLE can sort of band together and through the laws of large numbers keep their health care costs minimized by spreading out the risk over the course of large numbers of people and through levelized premiums. So in essence you pay a level premium month by month or year by year or whatever that you can theoretically afford so that if or when catastrophy strikes you won't have a huge doctor/hospital bill that you can't afford. The spreading of the risk amongst a large enough sector of people is what allows for this to occur.

Now the reason that group insurance and individual insurance are different in price and scope are two fold. First off group insurance through an employer is usually cheaper for the individual because there is a large group of people sharing the risk, because they are actively employed it is presumed that a large segment are healthy and that helps avoid adverse risk, and the employer generally helps pay part of the premium. Those three factors help kleep costs down. Whereas individual insurance is one person, no spreading of risk, high degree of adverse risk selection as many individaul people seeking health insurance are already sick, and of course no one helping offset the premium costs.

The reason for the seemingly skyrocketing costs of health insurance are not greed by health insurance companies as so often is portrayed. Insurance companies generally speaking have a "spread" on which they make their profit and that spread really hasn't changed in the last 30+ years. No the difference is the skyrocketing costs of healthcare being passed on to the public and inusrance companies by doctors, hospitals and pharmaceutical companies. Factor in the high costs of frviulous lawsuits levied against healthcare providers that increase their malpractice insurance to astronomical rates and combine that with the rampant fraud within the healthcare provider industry and those costs are then passed on to the health insurance companies which in turn have to raise their premiums to match what is being passed on.

The reality is our healthcare system is messe dup but it is also the best healthcare in the world period at the sametime. Ordinary average Joe likes to say things like "it makes me want to run back to Sweden" but in reality you already said why you don't, it's because the healthcare provided there is not the best in the world. Truth is our system would be LOADS better if you did a few what I think are simple things. #1 limit the amount people can get on these lawsuits and even get rid of the frivulous lawsuit standards in this country that allow for people to get "settlements" from good doctors who were only trying to legitimately help, would allow good doctors to practice good medicine without looking over their shoulders and without having to pay literally hundreds of thousands of doolars in malpractice insurance which they pass on to you in their costs (that doesn't mean a felon like doctor doing things with malice should't be able to be sued, I think we can figure out the difference as a society by and large)..... Second do not allow healthcare providers to own any part of or stock in health insurance companies, this type of thing helps contribute to fraud IMHO.... Third, regulate pharmaceutical companies better, no more givingg healthcare providers financial icnentive to push drugs on people that may or may not be necessary, no more advertising drigs on TV, you can't advertise cigarettes on TV you shouldn't be able to advertise drugs on TV, pue and simple if you ask me again this would allow doctors to more freely advise their patients with good advice. This would bring down costs astronomically if you did these three things.

Also, you can't have socialized universal healthcare AND have the high quality of specialty care and high degree of care we have here exist simultaneously and keep everyones taxes low and have low unemplyment etc... etc.... There are gives and takes and risks and rewards in different societies. I've been treated or had loved ones treated in places like Sweden and England, places people love to boast about, and you know what, the treatment was aweful. Long,, long waits, doctors who felt like they were treating with 20 year old science etc.... I'm sure it's not like that everywhee but be careful what you wish for. Understand the system better and maybe you can make the system work better for you.
Hope that helps!
Posted 11/15/2012 5:03 PM (GMT 0)
Good point about the root cause of the system bursting at the seams here in the U.S., butte1- it's the skyrocketing costs that are passed on to employers, insurance, and patients as healthcare inflation vastly outpaces general inflation. Also, let's not forget that in the U.S.., we do have essentially free universal healthcare, a la Europe and Canada, for all seniors as well as the very poor- the programs are called Medicare and Medicaid, and future taxpayers are in the hook for something like 80 trillion dollars for the unfunded liabilities those are projected to accrue in the next 50 years. Unlike the rest if the world though, we essentially have no caps on treatments and costs- every ither advanced country caps their "free" care. That lack of caps is another reason health costs 20% of GDP here and rising, vs half that or less for every other advanced country, even though most health outcomes are actually inferior here- most if the money is wasted, much of it on paperwork or treatments that extent life for a few weeks or months. It's a mess. I think rather than the best system jn the world, we have the worst of all worlds- private providers combined with in essence unlimited free benefits for the elderly, a recipe for fiscal meltdown.
Posted 11/15/2012 5:11 PM (GMT 0)
I would go without health insurance in a heartbeat if I knew that my medications could be obtained without paying exorbitant fees. My enemas are $10 a month with insurance but without? Try almost $300 a month for size. This is not including the other 3 meds I have to take. I know my docs would rather negotiate with me on a cash price for visits versus having to deal with insurance as they get more money from cash paying customers than from insurance plus my co-pay ...

Right now, hubby is on permanent disability so he has Medicare and can also go to the VA if necessary. I work for a small nonprofit that does not have healthcare benefits so I must find an individual policy for me and the two kids. I pay almost $1,000 a month through our Texas risk pool because I cannot qualify for insurance on my own and I cannot get a policy just for my kids due to TX rules. And I make too much to get my kids on the TX CHIP insurance program. So I pay $200 per child and almost $500 for me ... for the crappiest insurance with a $7,500 deductible. My kids have not been to the doctor for illness in over 3 years. Does $200 a month each sound fair? No ...

With Obamacare, they will likely issue $2,000 fines if you do not have insurance. Well, it certainly beats paying almost $12,000 a year for insurance that I am paying now! How screwed up is this? If it weren't for the fact of those "what if" scenarios where I could be possibly hospitalized again for my UC or some accident with my kids, I would drop the health insurance in a heartbeat. I am screwed six ways to Sunday no matter what I do. I have talked with officials in the TX department of insurance, I have talked to federal government officials regarding pre-existing condition insurance and really have done everything I can to find a more affordable alternative and there is not one. I cannot even find a new job with comparable pay and group health insurance. (And I don't want to quit my job because it is a perfect fit for me, as if I was born to do this.)

I wish I had words of wisdom about insurance but it just makes me sick ...
Posted 11/15/2012 5:13 PM (GMT 0)
The U.S. healthcare system is the most expensive in the entire world, however, it is not the most effective system by any measure of the word "Although the U.S. spends twice as much on health care as any other nation, the World Health Organization (WHO) reports that the United States ranks 50th in life expectancy and 39th on the overall health status of its citizens worldwide". So I wouldn't call the U.S. healthcare system the best in the world by a longshot. We also rank "49th for infant mortality, where we're barely ahead of Belarus, Croatia and Lithuania".
Posted 11/15/2012 5:15 PM (GMT 0)
Butte is confused. Let me unconfuse him.

Healthcare costs in the US = Bad
Healthcare costs in Canada = Great....what costs? I don't pay jack. lol

Healthcare quality in the US = Great
Healthcare quality in Canada = Great

UC knowledge in the US = nobody knows crap
UC knowledge in Canada, = nobody knows crap
UC knowledge in random country = nobody knows crap

By using this simple approach Canada is better than the US in terms of healthcare.

*applause* *applause* thank you, thank you...I love you all, thank you....you're too kind ...thank you *applause* *applause*
Posted 11/15/2012 5:24 PM (GMT 0)
"The U.S. healthcare system is the most expensive in the entire world, however, it is not the most effective system by any measure of the word "Although the U.S. spends twice as much on health care as any other nation, the World Health Organization (WHO) reports that the United States ranks 50th in life expectancy and 39th on the overall health status of its citizens worldwide"."

Who's no.1 ?, give me the link to the article, does it have a ranking?
Posted 11/15/2012 5:33 PM (GMT 0)
I've always read that France has one of the best healthcare systems but that it also is facing rising costs as it's populace ages.
Posted 11/15/2012 5:44 PM (GMT 0)
Somedude,

The US ranks 50th in life expectancy figure is cited based on this link "https://www.cia.gov/library/publications/the-world-factbook/rankorder/2102rank.html". Countries are ranked based on "life expectancy at birth". MOnaco is #1, Canada is #12, France #14, and US is #50.

The WHO has tons of interactive data and lengthy reports on their website: http://www.who.int/gho/publications/world_health_statistics/en/index.html

I just hate U.S. ignorance that we have "the best healthcare system in the world" as it is complete B.S., it might make a nice soundbite for a political ad or speech but the facts just don't back that assertion up.
Posted 11/15/2012 5:46 PM (GMT 0)
It all goes back to the almighty dollar. It is not profitable to keep people healthy and practice preventative medicine. Other countries around the world are light years ahead of the U.S. in this.
Posted 11/15/2012 5:47 PM (GMT 0)
"Somedude,

MOnaco is #1, Canada is #12, France #14, and US is #50. "

AHA!!!!

Canada #12,

US #50

Sweden # 16

LM.AO ...Sweden is in 16th place. "GO BACK TO SWEDEN, better there deltaforce", you were right, the first time.

lolololol

OMGZ...my home country, Romania, is in 109th place....sniff sniff....whyyyyyyyyyyyyy.......sniff sniff

Thank you ipoop for validating my story. Bless you my son, now you can go back to pooping. ;)

smilewinkgrin  

Posted 11/15/2012 6:42 PM (GMT 0)
There are pros and cons to all of this. You will find millions in the US who wouldn't trade our system for anything in the world. You will find millions in the US who hate our system and wished they could have any other system in the world. Obamacare won't change that.
Posted 11/15/2012 6:51 PM (GMT 0)
garylouisville,

Well, you see there's a good point and I wish a fact-based discussion could be made without all of the political rhetoric on the floor of u.s. congress. The simple fact of the matter is the U.S. system has its strengths and weaknesses and that in a nutshell is why some love our healthcare system and others hate it. As a strength, I am sure some of the latest research and equipment is available in some hospitals here if you have, for example, late-stage cancer, uncommon or a rare disease. However, the U.S. system is super inefficient at what it does, as the "most expensive in the world yet ranked 50th in life expectancy" thing drives home. Certainly, the U.S. has to get over it's ignorance that we are the best and look at the rest of the world as a model to what could be done here more effectively and efficiently.

I'm sure if you're a millionaire in the US then your healthcare would be extraordinary as the best drs, equipment, and such is available to you when cost is not a concern. However, if you are without insurance then forget it you're screwed waiting in line in a crowded emergency room or go bankrupt, drowning in debt due to out of pocket costs for care. I have a neighbor who's father died in his mid 50's (the father drank himself to death) with no insurance and he now has $45,000+ in hospital bills and the death of his father to contend with. If you are lucky enough to have insurance you are only allowed to go to in-network drs and facilities (keeping you away for the best options like the millionaires have). And the high deductibles, and lifetime caps just pile on the costs.

I know the topic is supposed to avoid politics for the most part, but obamacare is just one babystep. The conservatives have good ideas too ("tort reform", shopping for insurance across state lines, among other ideas) and I wish those ideas could be combined with the liberal ideas like obamacare. Basically throw everything at the wall and see what sticks, along with as much research as can be used without all the made for tv drama and rhetoric from both sides of the isle. Since overall cost needs to be addressed and I think both sides have ideas that could very well work and we won't know for sure unless they are all tried.
Posted 11/15/2012 8:16 PM (GMT 0)
I agree health care reform is not done. There will certianly be tweeks, and IMO there will need to be some ways to keep costs down.

In the larger discussion about "best". IMO a lot of the confusion results form failing to distinguish "the best is available" for a price, from "best system available".
Posted 11/15/2012 8:49 PM (GMT 0)
I hope there are a lot more tweeks, as so little has been done.

The best care is measured on a global scale by the World Health Organization (WHO) and by others. And we rank very poorly. No matter how you define "the best" healthcare system it must work for everyone not just the richest among us. As I'm sure millionaires across the world get the best care available regardless of the country in which they reside (and they'll go to world renowned drs and care centers the world over in order to get it in a lot of cases).
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