Monday, August 24, 2009

My story of medial rationing

Something that can't be said often enough or loudly enough during the ongoing heath-care reform debate: Most of the dire things protestors and reform critics are most anxious about are happening now.

Want to see a real death panel? Go before an organ transplant board. Scared of waiting two months for an appointment with your family doctor? In Boston, the average wait time is currently 63 days. Worried that scarce and expensive health care will be rationed? It already is. The only difference is that the decision-makers about who gets care and who doesn't are insurance companies, not government-backed organizations.

Three years ago, we had a health care scare in my family. David and I are among the medically lucky: We've always had plans provided by large, multinational employers with relatively deep pockets. An ambulance ride, a night in the ER, a week in the hospital, and prescription drug costs of around $120 a month were covered with fairly little fuss. Of the roughly $20,000 that emergency week cost, we paid only around $1,500 out of pocket.

But this health scare necessitated weekly follow-up visits, initially with more than one specialist. It happened literally in the very first week of the year -- after I'd made my health care elections and locked in my FSA contributions (then at $0, because we'd never before used much medical care). In the 52 weeks that followed, about 60 follow-up appointments were required.

These weren't optional. I had letters from three different doctors attesting to the extremity of the situation and the fact that, in their opinion, this was a potentially life-and-death situation.

But our medical plan capped outpatient visits at 30 a year. Somewhere in my filing cabinet I have a letter where the company explains that in this case, the medical necessity of the appointments was irrelevant. Having letters from doctors saying "left unsupervised, this could result in death" didn't matter at all. What mattered was that the fine print of my insurance plan said that beyond 30 visits a year, the company would not pay a penny, no matter what.

So we had a choice: Come up with $125 a week for these appointments, or take our chances without.

We're lucky. We were able to scrounge up the almost $4,000 a year that cost (on top of the $1,500 in out-of-pocket costs for Emergency Week, the $3,000 a year we already paid toward our work health-insurance plans, and the $500 we spent that year on prescription co-pays).

But if we hadn't been able to pay? No health care. If the result of that had been death, the insurance company would have had no liability, because in this case, it was completely within the terms of its agreement to entirely disregard the medical needs of its clients.

So when people drag out scare quotes about government health care rationing, I get extremely cranky. Doctors, drugs, hospital beds and the money to fund all of the above are limited. There is a reasonable debate to be had about how those resources should be allocated.

But let's not go into it pretending that we're not already making some brutal decisions about who gets care and who doesn't.

And if you're one of those who, like me, has a nice cushy corporate insurance plan, don't think you can't land in a situation where you're left without essential medical care.