An interesting story from the Boston Globe:

Geneva Fielding, a single mother since age 16, has struggled to raise her three energetic boys in the housing projects of Roxbury. Nothing has come easily, least of all money.

Even so, she resisted some years back when neighbors told her about a federal program called SSI that could pay her thousands of dollars a year. The benefit was a lot like welfare, better in many ways, but it came with a catch: To qualify, a child had to be disabled. And if the disability was mental or behavioral — something like ADHD — the child pretty much had to be taking psychotropic drugs.

Fielding never liked the sound of that. She had long believed too many children take such medications, and she avoided them, even as clinicians were putting names to her boys’ troubles: oppositional defiant disorder, depression, ADHD. But then, as bills mounted, friends nudged her about SSI: “Go try.’’

Eventually she did, putting in applications for her two older sons. Neither was on medications; both were rejected. Then last year, school officials persuaded her to let her 10-year-old try a drug for his impulsiveness. Within weeks, his SSI application was approved.

“To get the check,’’ Fielding, 34, has concluded with regret, “you’ve got to medicate the child.’’

There is nothing illegal about what Fielding did — and a lot that is perhaps understandable for a mother in her plight. But her worries and her experience capture, in one case, how this little-scrutinized $10 billion federal disability program has gone seriously astray, becoming an alternative welfare system with troubling built-in incentives that risk harm to children.

I suppose it’s only a sense of ethics that would prevent Fielding from simply throwing the drugs away (and the law from selling them). It’s an interesting dilemma. I don’t have any problem helping out parents with kids that have disabilities. My ex-sorta Delsie ended up marrying a man with a disabled (like, seriously disabled) daughter and even though she’s very positive and upbeat it sounds like a real handful. And really expensive.

Of course, when you implement these programs you always have to be on the lookout for perverse incentives. Whether Fielding is genuinely doing wrong or not is unsure. That’s part of the problem when it comes to issues like ADHD, depression, and other things. With Down Syndrome, it’s an up-or-down thing. A kid with serious autism pretty obviously has something abnormal about them. But a lot of psychological issues are difficult to nail down. There’s no good blood-test and brainscans and the like are expensive and as much a product of learning about disorder (through subjective diagnosis) than objective diagnosis. This has (unfortunately) lead some to believe that the entire disorder (ADHD in this case) is really a “disorder” or simply a product of or metaphor for our times. Or that it’s simply a matter of laziness.

Daniel Carlat is a doctor frustrated with parents coming to him for the reasons cited in the Globe article:

As a psychiatrist besieged by patients asking me to diagnose them with ADHD so that they can get a prescription for Ritalin, I both agree and disagree with Dr. Klass. Yes, there are clearly some patients at the extreme end of the severity spectrum whose brains simply won’t allow them to focus. These are the patients who end up being enrolled in all the “convincing” neurobiology studies outlined by Klass — the studies that suggest that ADHD might involve frontal lobe problems and dopamine deficiencies. But for every child or adult with obvious ADHD, I suspect there are several who have a “soft” or even, yes, a “mythical” version of the disorder.

The prototypical mythical case is the parent of an ADHD child who comes into my office saying that he or she tried their child’s Ritalin and found that suddenly they were incredibly productive at work. “I think I must have ADHD, doc.”

I then have to explain that Ritalin is a version of that old college term-paper completion engine — speed — and that studies show that just about anybody who takes an ADHD drug thinks more quickly and focuses more acutely. That doesn’t mean you have ADHD.

But what does? The inability to really answer that question is as much the problem as SSI, video games, medication nation, and a host of other things. That doesn’t, as Carlat notes, make it entirely mythical. But the ambiguity of it all is pretty problematic. It can be an attractive excuse for failure for some. If your kid having ADHD or not having ADHD is the difference between a few hundred dollars a month and better medical care, it’s not difficult for even honest and well-intentioned parent to determine that their kids probably have it. The ambiguity around diagnosis may make it hard for a psychiatrist to argue otherwise (and they can always find another psychiatrist if they do). It’s really not surprising that people would respond to these incentives. Some are dishonest, some are conflicted like Fielding, but a lot will simply believe what it is advantageous to believe.

A couple of Wall Street Journal articles of interest.

First, an article about consolidation in the health care industry:

Unlike Medicare and Medicaid, private reimbursement rates are determined by negotiations, often highly antagonistic. Insurers always attribute premium increases to the underlying cost of care, while doctors and hospitals always argue that there isn’t enough competition among health plans. Both claims are “true,” some of the time—but it depends on which side has more market power.

Insurers extract lower rates by steering patients and revenue to certain providers through their networks. Providers gain bargaining leverage when health plans can’t credibly threaten to exclude them, whether because their share of the market is too large or due to public demand for “must have” hospitals. Consolidation will increasingly feed off itself as providers and insurers vie to get the whip hand in rate negotiations.

Most neutral experts believe the balance of power has tipped toward providers over the last decade, though this isn’t always anticompetitive. Higher rates generally reflect investments in staffing, technology, specialization and sometimes consumer preferences. There is also the cost-shift to private insurance to offset Medicare’s price controls. However, most economic studies on hospital M&A over the last two decades show that consolidation increases unit prices, though there is significant disagreement over the magnitude.

If most neutral experts believe it, it’s probably true. A few factors are worth noting. If providers have increased leverage, it’s due in part because they’ve had to make sacrifices to get it. As the article copiously notes, consolidation in the health care industry is increasing. The local hospital bought up a number of the local doc practices and Clancy is an employee in the hospital. The job she interviewed in Gemini Falls was also part of a large, multi-practice group. Autonomy used to be one of the big plusses when it came to doctors but it’s no longer worth it. It’s sort of like an invading army forcing a local medieval town into the castle. Yeah, they residents have got the high ground, but only because they left where they want to be.

And I have to take this moment to point out that physician wages have, despite the leverage, been stagnant*. So where is this extra money going? I would guess it’s as the article said: infrastructure improvements. Probably increased administrative staffs, too. Clancy’s employer is building a new hospital, for instance (but they’ve also forced an essential wage-cut amongst at least some of the doctors). Another area of concern is that a lot of these infrastructure improvements can be geared towards things that will ultimately increase the costs of health care in the long run. Buying new machines that will perform expensive tests and the like**. Once you have these machines, you want to use them! So care and testing will probably become more aggressive and, hence, more expensive. There’s not much good to be said about the doctor shortage in this country, but in some ways it probably is keeping health care expenses down. You might pay doctors more than you otherwise would, but there are fewer doctors performing aggressive and ultimately unnecessary treatment***.

Also, did Medicare kill the family doctor?

Eventually, that disconnect (and subsequent program expansions) resulted in significant strain on the federal budget. In 1966, the House Ways and Means Committee estimated that by 1990 the Medicare budget would quadruple to $12 billion from $3 billion. In fact, by 1990 it was $107 billion.

To fix the cost problem, Medicare in 1992 began using the “resource based relative value system” (RBRVS), a way of evaluating doctors based on factors such as education, effort and specialized training. But the system didn’t consider factors such as outcomes, quality of service, severity or demand.

Today most insurance companies use the Medicare RBRVS because it is perceived as objective. As a result of RBRVS, specialists—especially those who perform a lot of procedures—do extremely well. Primary-care doctors do not.

The primary-care doctor has become a piece-rate worker focused on the volume of patients seen every day. As Medicare and insurers focused on trimming the costs of the most common procedures, the income and job satisfaction of primary-care doctors eroded.

If you wonder why it’s so hard to get much of a doctor’s time, this accounts for a lot of it. As mentioned before, doctorly pay has been stagnant. This is due to the fact that doctors have made up for what would be substantial losses by seeing patients in much more rapid succession. Due to the general nature of their work, there can simultaneously be a shortage in primary care (both in absolute terms and relative to specialists) and primary care physicians can be seen as “a dime a dozen” when it comes to negotiation. The result is fewer and fewer doctors going into primary care and more and more specialists which end up limiting what primary care physicians can do (for instance, Clancy can only perform cesarean sections because there are no obstetricians in town to object) which ends up making it so that primary care physicians get to do less of the things that might provide job satisfaction and pay boosts.

Specialization doesn’t have to be a bad thing, but at the very least you need a more complete “front line” to screen patients and refer them to specialists. This is an area where having mid-level providers may be more of a help. Or importing more doctors. I am skeptical of the notion that having more primary care docs (or docs in general) will lower health care costs without other substantive change, but it could help the front line problem. The only alternative to the supply-side is the demand-side, and it’s difficult to ask patience to triage themselves, determine that they don’t need care after all, or to seek the cheapest available option when their copay is the same no matter what they do.

One idea I have been toying around with is shifting more of the primary care to the government or insurance companies and let them worry about containing costs. I am not sure how much I trust the government to contain costs and I’m not sure how much I trust insurance companies to give patients a fair shake.

* – This isn’t a complaint. Doctors are still very well paid.

** – I don’t have any information on whether any of this is going on at Clancy’s hospital. But it’s an industry-wide issue.

*** – Some of this may be in the form of doctorly profiteering, but that’s not even what I am referring to here. Tests can be unnecessary but still be beneficial. Think of it like taking medicine to get over a cold two days earlier than you otherwise would have. It’s not necessary, but it’s nice. It’s nice, but it ultimately costs the system money. One of the peculiarities of the health care industry is that the two primary decision-makers, doctors and patients, often have little incentive to consider costs of treatment. Those whose job it is to consider costs, insurance companies and the government, face really bad publicity by stepping in and stopping payment on what a doctor thinks would be beneficial and a patient wants on the grounds that the substantial cost outweigh the smaller but potentially very real benefits.

The Well has an interesting piece by a doctor regarding the difference in managing health care for people versus those of our pets:

My own patients have a far harder struggle in every respect. My foray into the insurance world as a patient exhausted me and pointed out everything that was wrong with our health care system. How is that the simplest routine medical matters have been made so complicated by our insurance companies? Why does every encounter require a veritable girding up for battle? And how many patients do not get the care they need simply because they are defeated by the bureaucracy?

There’s a lot we can learn from animals in many facets of life — Lord knows, a nice massage behind the ears could do a lot of us some good — but I am consistently impressed by how much smoother veterinary medicine runs. Of course it’s too simplistic to make a direct comparison, but I hope that in this ongoing health care reform we consider ways to make things easier for patients.

As Dr. Ofri points out, insurance companies don’t exactly have incentives to make collections easy. I agree with her that it’s not an accident that they make it as complicated as they do. I don’t think it’s a huge conspiracy, but they have no incentive to make it simple and the specificity that comes with making it difficult benefits them even apart from discouraging people from making claims.

Conservatives will be quick to point out that one of the chief differences between animal health care and human health care is that the former is purely market-driven while the latter is a combination of public, private, and private but driven by public policy (namely health care tax exemptions for employers). This is quite true. Veterinarians have every incentive to make pricing as transparent as possible and without the intrusion of insurance companies they don’t have to negotiate different rates with different entities that leads not only to opacity, but disparate pricing.

This is one of my main frustrations with our health care system, though it could be addressed either with a market system or a purely socialized system. Namely, when I go visit the doctor I have no idea how much I am going to pay. I don’t know what the insurance company is going to quickly agree to and what they’re not. And then, if they don’t agree, then suddenly I am on the hook for more than I would have paid if I’d simply paid up-front. There’s no way of knowing, up front, what the cheapest method of paying is. Since I am healthy I saved money when I was on catastrophic health insurance, but what I remember most fondly about it was the fact that since I knew I was paying for all non-catastrophic care out-of-pocket, I didn’t have to worry about any of this stuff. Even under the current system, when you tell them that you’re paying up-front, the pricing becomes a lot more transparent and you can even save money in the process as they will often charge you less than the listed price in return for not having to submit claims to insurance companies.

However, there is another significant difference between human and animal care, which is that we as a society are willing to let animals die for non-payment and we’re simply not willing to let humans do so. This changes a lot and makes a purely free-market health care system very problematic. Since we force emergency rooms to treat anybody and everybody that comes in, people that are uninsured can simply go there if they’re worried about it, racking up substantial bills that they will never be able to pay but who cares because they need the help now. This ratchets up the price on those that can pay who have to pick up the tabs for the former. (Yes, I am aware that illegal immigrants play a role in all of this, but if they all disappeared tomorrow we would still have a problem in this general area. And this is not a post about immigration.) And apart from emergency rooms, when you force insurance companies to pick up the tab on people with pre-existing conditions and people know that they can get insurance at any point and coverage will be assured, they can wait until they get sick before they get coverage. We are simply far more reluctant to deny care to people than animals and this has wide-ranging repercussions.

Anyhow, back to the health insurance companies. It’s easy to attribute the Charlie Belcher Theory of Economics to the insurance companies that they are only denying care and making payments difficult because they want more money. Insurance companies are an easy target and I dislike them myself as a matter of course. On the other hand, I have been covered by for-profit and non-profit insurance companies and I can’t say that I ever really noticed a difference in terms of paperwork and thriftiness. They all have incentives to hold down costs and even the for-profits tend to have small profit margins (which they make up for in volume). The only really good insurance company I’ve ever felt really comfortable with is our current one. It could be related to the fact that they’re not-for-profit, but I also wonder if they treat us differently because they know my wife is a doctor or she works at a hospital.

The biggest problem with insurance, as I see it, is not so much the profit motive as it is the incentives. They have no incentive to make it easy on us because we’re not the ones that chose them. In some ways, our current system is the worst of both worlds where we have profit-seeking by many of the players but not the consumer choice that guides these institutions to serve the consumer’s needs. Not just on price, but on simplicity and transparency. They have to be cheap in order for our employers to sign with them, and if they don’t cover anything the employers won’t sign with them, either, but they can thread the needle by being opaque enough and, from their perspective, it’s easy to justify the opacity as caused by the cloud of the inherently complicated nature of health care generally.

According to a top doc in Britain, smoking in the car with children is child abuse. Well, that’s what the article’s title says but the article doesn’t quote him as saying that. I am actually not entirely unsympathetic to this argument as such. It seems to me that smoking in a car with young children does present a health hazard and while in the absence of laws banning smoking in restaurants (for instance) that adults can avoid, the children are captives. Cars are pretty small and can get really smokey really quickly if the windows aren’t more than just cracked open. When I was a kid, Mom would open the windows unless it was raining outside in which case the car would just get really, really smokey.

The doc goes a bit further, though, in arguing the same is true for parents that smoke at home in front of their children. This has got me thinking about some of Sheila’s recent post about the CPS and pot and makes me wonder when we will approach the day when smoking inside the home or in front of the children will be considered some sort of abuse. I think we’re a long ways off from that, but as smoking becomes more and more something that poor and dysfunctional people do, I could genuinely see it happening. Even if the smoking itself isn’t considered so terrible (for the kids), it could be one of those things that gets the CPS’s attention. And it seems that as I learn more about the process, the best way to deal with the CPS is to avoid their attention in the first place.

But I found this comment to be bizarre:

“Evidence from the US indicates that more young children are killed by parental smoking than by all other unintentional injuries combined.”

Errr… by what measure, exactly? Smoking isn’t one of those things that kills you on the spot. Generally speaking. Second-hand smoke even less so. So how is it killing young children? How is it doing so more than all other injuries combined? The only way I can think of this being remotely true is if you count deaths that occur later by conditions incurred when they are young children. Or maybe smoking when the child is in the womb making the infant’s life a very short one. Even so… all others combined?! In the first case, how do you control for other variables such as the fact that children of smokers are more likely to become smokers themselves (due not only to parental example, but genetics)? All others combined?! I have to think that swimming pools, sports injuries, and (these days) extreme food allergies would be larger threats.

Maybe I’m missing something, but without elaboration it strikes me as a number of other “health facts” that I heard growing up that were and are transparently false. I remember being told in the 5th grade that second-hand smoke was actually more dangerous than first-hand. That could only be true if you’re looking at second-hand smoke affecting more people, but that did not seem to be what they meant. Besides which, I am willing to bet in a household of four where one party smoked and the other three did not that the first is more likely to die from tobacco-related illness than the other three combined despite the 3-to-1 ratio. There is a world of difference between breathing something in the air and sucking it straight into your lungs. It, like the doc’s quote, strikes me as one of those things you say to reinforce the point that smoking is not a strictly private behavior. But it does not have the benefit of being credible. At least not without a thorough explanation of how you’re assessing comparative danger.

A couple weeks ago I discussed the gray area involving pre-existing conditions (PEC) and health insurance companies. In the comments, I made an allusion to a health care company that I signed up for that sheds some light on the issue.

Assurant Health specializes in offering short-term health insurance options to people that want individual or family policies apart from employer-financed health care. The terms they attach to their policies actually put their coverage between “insufficient” and “utterly useless.”

Assurant specializes in offering “insurance” on the cheap. Their plans are generally high-deductible and even after you meet your deductible you’re still on the hook for 20%. They may offer a permanent plan, but the policies I’m looking at are their “short-term” policies. Those are the policies that are half-useless. But they do fill a market void.

The way it works is this: You sign up for a plan and it can last for up to six months. The last time I used them, they cost $75 a month despite my smoking. The deductible was $2500 and, as mentioned, you were still on the hook for 20% once you passed your deductible. I’m not sure how much they charge now, though their web site says plans start at $60.

The catch is, though, is that after six months you cannot renew. You have to apply again. Therefore, any illness you got in the previous six months becomes a PEC. And if in the interim you get cancer, there is a good chance that they will refuse to cover you altogether. Which may be just as well because they won’t cover PECs in the first year** on their permanent plans (which cost twice as much) and you can’t get a policy for more than six months.

So why would anyone sign up for this plan? Well, if you get a sudden-but-temporary illness, they’ve got you covered until the policy expires. If you have an accident, you’re covered there, too.

But the reason that I signed on was solely to avoid the gaps in coverage I talked about in my previous post. In essence, I was paying them just so that I would be able to tell future insurance companies that I was insured. Which is kind of screwy, when you think about it.

I’m honestly a little surprised that the insurance companies let us get away with this. You would think that they’d lobby congress to only certify plans that meet specific criteria to count. It’s very likely that, if there were a PEC requirement, we will start to see more such lobbying. Not all of Assurant’s plans are allowed in all states and Assurant does not serve a handful of states. With the exception of some western states, the states with limited services are Blue States. So I suspect it’s a question of how tightly states are regulated rather than state legislatures being overly deferential to Big Insurance (not that these things are mutually exclusive).

Nonetheless, it’s a handy thing to have around for people that can’t afford better coverage. Clancy and I may have to re-evaluate our insurance options soon (her COBRA plan is wicked-expensive and not reimbursed by ARRA). We’re in a good enough financial position that we don’t have to accept this sort of half-coverage, fortunately.

** – You have to have a gap in coverage for PECs not to be covered under group (ie employer) plans. The same is not true for individual policies.

UPDATE: Problem solved! Phew. We’re waiting in anticipation on a possible job offer from Gemini Falls. I think I’ve been much more stressed out. Everybody wish us luck!

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For those of you that have never had to use COBRA, it’s a pretty good thing. Basically, the government told employers that they cannot tax-deduct health insurance unless they supply a plan that allows 18 months of coverage after a person loses their job (for any reason except malfeasance). So employers in turn lean on insurance companies and insurance companies reluctantly comply.

The problem with this sort of government-enforced transaction is that if a company does not want to do business, they can be pretty resourceful about finding ways not to. They delay sending out the paperwork by a month or more, hoping that you’ll make other arrangements. You get 60 days to sign up and if you miss that deadline then they absolutely, positively will not continue your coverage. All claims until the paperwork goes through are denied and you’ll have to recoup the money later. Then, when everything gets settled, you have 30 days to back pay everything you owe, so you have to have three months’ worth of premiums on hand. If you weren’t saving for that like you should have been, tough luck.

I knew all this when I signed up for COBRA, so I expedited things by signing up on their website. I didn’t want there to be any chance of my check “getting lost in the mail”. I also made darn sure that I paid all of my premiums over a month in advance so that they couldn’t make any claims about when the check did or did not arrive. But apparently, even doing everything right is not necessarily enough.

We’ve been simultaneously lucky and unlucky here in the Truman household. Rather, our luck has managed to mitigate the damage of our extraordinary unluck. Although I don’t know if you can call it unluck if it’s dependent on the bad-faith actions of others. In this case, the culprits are former employers and insurance companies.

We came back home from our Great North by Northwest Jobs tour a little bit earlier than expected. It actually wasn’t a welcome development because we were hoping to swing back by Gemini Falls and sign some papers. But home we came and it was a darn good thing we did. In the main was a letter from the health insurance administrator informing her that her COBRA enrollment period had lapsed and she is not only uninsured, but has been uninsured for the all-important 60+ days.

This was crazy because we knew for a fact that she sent in the money. We also know that the mail was taken that day because another letter sent that day was received a couple weeks prior. So she called her health insurance administrator* (HHIA) and they said that they had in fact received the check but that ARRA** had been denied so they sent it back with a letter explaining that she needed to write another check (for more money).

So suddenly her insurance went up from $200 a month to $600 a month because the federal government wasn’t going to kick in. Why wasn’t the federal government going to kick in? Because her former employer declared her termination “voluntary”. Given that she was on a one-year contract just like I was and that (immediate) renewal of said contract was not an option, that just didn’t seem right to us. Either her employers were being jackholes or my employers were being unexpectedly generous. I’m disinclined to believe the latter. But whatever.

We had 14 days from the date of the letter to get them the contract and full amount of the policy back to them. This was on a Friday. Day 14 was Monday. We could fax them the signed contract, but not the money. Further, that Monday we were going to be driving back to Gemini Falls for a second interview. Long story short, their corporate headquarters was in Zaulem and I woke up at an ungawdly hour of the morning to go out there and hand-deliver the check. It turned out that the 14 days was 14 days inclusive and ran out on that Sunday. Fortunately, they’d put a flag on the account and so they were going to give us an extra couple of days. That was the only good turn we got from just about everyone we’ve dealt with.

About the same time that we got the letter from HHIA, I got a letter from my New Health Insurance Administrator (NewHIA) saying that FIREA, my former employer, had signed a contract with them and that they would be taking over starting on 12/1. They also sent me an Open Enrollment letter to. Notably, it would be cheaper for her on my insurance than it was on hers***.

It was cheaper with or without ARRA assistance and the wording was vague as to whether or not I could get ARRA assistance even though it had been denied for her. My guess is that we cannot. But even then it’s cheaper and I feel better paying one health insurance administrator rather than two. But I thought I would call NewHIA and see if ARRA might be covered and what the bill would be.

That was when the anvil fell. NewHIA informed me that my policy had been canceled. I had to sign up within 60 days of eligibility and I became eligible at the beginning of August. I should have received a letter. But the only two letters I had from NewHIA were the one informing me that they were taking over (and that I had a bill to pay before 12/1) and another about Open Enrollment. Long story short, as far as they knew, I’d never signed up with OldHIA. Except that I had and I was actually a month ahead on my dues because I paid a couple months ahead. A whole lot of good that did me.

NewHIA told me to contact OldHIA and have them forward my information. OldHIA said that they really couldn’t do that, but at the end of my policy they could send proof that I had been insured. That was not acceptable because that would create a gawdforsaken gap that could give NewHIA cover to cut my COBRA coverage completely (again). I asked them if they could send me a copy of the document. She put me on hold, came back, and said she could. But it would take two weeks. In two weeks, my coverage lapses.

I called NewHIA again and got a very unhelpful woman who said that there was nothing she could do without something from OldHIA proving that I had been insured. She suggested I call FIREA. So I called FIREA and they said that they would look into it. Perhaps she was just a good actress, but I got the feeling from her that she actually will.

So that’s where things stand right now. I actually run a not-insignificant risk of having my insurance cut off due to no fault of my own. I signed up within 14 of the 60 days alotted to me to sign up for COBRA. I have not only paid every bill on time but I am actually a month ahead. But none of that matters because NewHIA and OldHIA can’t talk to one another and I’m relying on FIREA, a company that has not been a friend to me and that could care less if my insurance is cut off. NewHIA will not accept an enrollment form or a check as long as my account is listed as “canceled”. Further, I’m going to be out of town for the remainder of the month starting on Friday and I won’t be back until after the lapse date, so I can’t have anything mailed to me. I’m not sure that matter because everything seems to take 5-10 business days to get mailed anyway.

And even if this does straighten out, there is virtually no way that I can get Clancy on my plan. That’s due on Friday and they’ve made it clear that there are absolutely no exceptions. The likelihood that this will all be straightened out Friday is pretty small. If ARRA doesn’t cover it, and I don’t believe it does, it may not be worth the effort anyway.

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* – Health insurance administrators appear to be all the rage. Basically, instead of dealing with your employer or the insurance company for your health insurance, you deal through a third party that coordinates it all. Somehow, this adding of another layer of organization is supposed to save people money. Maybe by creating miscommunications like this.

** – ARRA is the part of Obama’s stimulus wherein the government helps unemployed people by paying 65% of their insurance cost.

*** – This is sort of topical. Republicans are trying to allow for insurance companies to “shop across state lines”. As it happens, I am insured by Blue Talon of Estacado, the same insurance company that I had when I was in Estacado. Since my employer is based out of Estacado, they can get away with that I guess. I doubt it’s a coincidence that insurance in less-regulated Estacado is cheaper than insurance in more-regulated Cascadia. I’m probably not as protected, though.

One of the ongoing factors in the Health Care battle in congress is the issue of pre-existing conditions (PECs). It’s one of those issues where it is hard to strike a compromise that is fair to both consumers that have PECs and the insurance companies (and, by extension, their customers).

On the other hand, if all pre-existing conditions are covered no matter what, there is little incentive to get health insurance until you need it and an incentive to get something high-deductable until you need an insurer that’s going to cover whatever it is that ails you. Some, such as Megan McArdle, argue that this is not really such an issue, but I would expect it to become a much larger one as people get accustomed to the idea that they cannot be denied insurance due to a PEC. As it stands, I know someone that was uninsured, needed surgery, and cheated a single-issue insurance company by not disclosing it.

On the one hand, if PECs are never covered, people who happen to get sick while ininsured are forever locked out of the system even if they’re uninsured for brief periods of time. Or even if you were insured at the time, but for one reason or another have to switch insurance carriers. Further, PECs are frequently used by insurance companies for the sake of rescission.

Rescission, for those of you that don’t know, is when a policy is retroactive vacated. Insurance companies claim to do this when a customer was not up-front about a PEC. The problem is that some of the PECs used to vacate policies are things that a customer doesn’t even know about or that does not strike someone as significant (particularly if it’s something that hasn’t come around in a while). For instance, someone with a family history of heart illness or that had an irregular heartbeat in 2003 could find his policy vacated in 2009 when the insurance company finds out and argues that it needed to be informed.

The current balance that has been struck is that as long as one has maintained consistent coverage without a lapse over 30/60/90 days, they cannot be denied coverage on the basis of a PEC. State laws vary as to what length of lapse is acceptable and how long PEC coverage can be denied. In Cascadia, you have to have a lapse for greater than 60 days or so and if you have one they can deny you for up to 12-18 months. Further, rescission is generally only available to single-issue policy holders. In other words, you generally are not cut lose when covered through your employer.

This strikes me as a not-unreasonable balance, though I’m not sure it’s sufficient or proportional.

To take an example from the Truman-Himmelreich household, there was a snafu in the paper work for Clancy’s COBRA coverage* that lead us to find out, more than 60 days after coverage lapsed, that she had not been covered. So by default, we’ve already got a lapse that prevents anything pre-existing from being covered for a year. And I believe Cascadia is the most generous state I’ve lived in as far as this goes. I don’t believe Delosians are similarly protected, though I could be wrong about that.

As mentioned above, you generally have to have some sort of penalty for people that let coverage lapse during health, but the difference between enrolling in 70 days and enrolling in 59 days should not be that dire. A more fair approach would be to say something like “PEC do not have to be covered for whatever time period one was uninsured.” So we would not have any PEC coverage for 70 days. That seems fair to me. We would not have an incentive to wait as long as we wanted until we needed it since the longer we waited the longer it would be before we were completely covered. As it stands, we would have to wait nearly as long (within six months, anyway) as someone that went five years without coverage.

Rescission is a tricker issue. On one hand, insurance companies ought to be able to deny people that cheat the system. People should not be able to do what my friend did. The law didn’t stop him, but that’s only because the insurance company did not know. Meanwhile, however, insurance companies have picked up the practice of taking someone’s money until they suddenly have need of the services offered and only after that investigating someone’s application form and finding some (alleged) discrepency.

If an insurance company is collecting someone’s money, they ought to be relatively assured that they have coverage. Only those cases where insurance companies have reason to believe that fraud is involved should they be able to rescind. Insurance companies say that’s what they’re doing now, but frankly I do not believe them. They have too much financial incentive to do otherwise.

My proposed solution to that would be similar to the previous. Once an insurance company has been collecting premiums for a specified period of time (I’m inclined to say six month or a year), they should not be able to rescind a policy. Someone that hasn’t made any substantial claims in a year but continues to pay their premiums has demonstrated a degree of good faith. Someone that needs knee surgery is not going to pay $300-800 a month for a year just to collect benefits. Someone that is at risk of a heart condition didn’t start buying insurance with the plan of having a heart attack in a year’s time.

Now, both of these cases would have an exclusion for outright fraud. The difference between that and now is that the insurance company would have to prove that any reasonable person would know that a PEC was relevant. In other words, a heart attack a year before the policy could be considered fraud, but a heart murmur four years prior would not. A pack-a-day smoker that does not disclose his habit would be game, but family history that may have escaped their mind would not. Beyond that, the insurance company has the option of paying for (or splitting the cost of) a complete physical rather than not worried about it until it suddenly becomes very convenient to do so.

The other issue at play is that as medical records become more electronic, it’ll become harder and harder for people to knowingly (or unknowingly) hide PECs. There are questions as to what the insurance companies should and should not have access to versus the right of doctor-patient privilege, though it could well be that a compromise could become that if a person submits all of their medical records that there can be absolutely no rescission. Right now it’s not easy to collect that information, but it’s one of those things that (for better or worse) is going to become a lot easier in the coming decades.

* – For those of you that don’t know about COBRA, it’s a pseudo-mandate by the government that requires insurance companies not to drop coverage if you lose your job. What happens is that you get COBRA paperwork after you lose your job (for any reason excluding malfeasance) and if you respond within 60 days and pay the bill, you’re retroactively covered.

The downside is that you have to foot the bill that your employer previously footed. In a case like mine, that’s diddly. But when employers are actually generous with their benefits, you can see your premiums jump three-fold or more, as was the case with Clancy. The other downside is that since COBRA was something that was thrust upon them by the government and the policy-holder’s employer, it’s not something that they’re excited about and it’s frequently the case that they don’t want your business.

On the other hand, President Obama’s stimulus package included a provision wherein the government will pick up 65% of the tab. For people like me, that means that COBRA is cheaper than penny-pinching employer-provided health care. For people that have more generous benefits like Clancy, though, it’s still going to cost more.

I happened to catch this story on the Today Show this morning:

Lauren Johnson is a typical 12-year-old girl – except that she can’t stop sneezing.

It is so bad that she sneezes up to 20 times a minute, or 12,000 times a day.

The non-stop sneezing began two weeks ago when Lauren from Virginia in the U.S. caught a cold.

Lauren can’t go to school and is even struggling to eat.

The only relief she gets is when she falls asleep each night. Her condition has left doctors baffled.

Cynically, my first thought was that she simply figured out how to sneeze on cue and is faking it (particularly since it doesn’t happen in her sleep), but she sold me during the interview. Not only does she look miserable, but she looks a particularly disconcerted sort of miserable that I don’t know a twelve year old would think to use.

What really stuck out in the story was all of the tasteless puns TTS was throwing out there. Pretty tacky.

Sometimes we want things from society and the law that we cannot get. For instance, you may believe that abortion is murder or that the death penalty is wrong. However, in most places (well, all places in the former and most places in the latter), you are unable to actually do anything about it. It’s a frustrating situation to be in. Most of the time when this happens, though, we view some wrongs as being more wrong than others. I’m opposed to the death penalty, for instance, but if we’re going to have a death penalty then we ought to try to make sure that (for instance) those that are executed are not tortured in the process and that innocent people are not executed.

Despite my fundamental opposition to the death penalty, I tend to get annoyed with death penalty opponents who play a sort of cat-and-mouse with partial measures. It’s one thing not to want someone to be executed in a way that is tantamount to torture. It’s another to say that method-X is torture. But to suggest that method-X is torture is primarily to suggest, in the short term, that some non-tortuous method is used. The trouble is that when you turn around and suggest that any alternative is still killing people, you’ve undermined your case against method-X. You have revealed that your opposition was to the act and not the method involved. You’ve alienated anybody who generally supports the death penalty but was concerned about method-X. If method-X is genuinely torture, you’ve possibly consigned people to death row to a more tortuous death than would otherwise possible. If method-X is not really torture, you’ve been remarkably dishonest and people (who already disagree with you in bulk) are not unlikely to notice. On the other hand, if and when method-X is replaced by method-Y, you’ve lost a good portion of your argument if your argument was never really against method-X to begin with.

This is why the whole argument about the lethal injection formula at work in our death chambers left me somewhat cold. The fact that the point was never to switch to a more humane method left me skeptical that the fomula (method-X) was really as bad as they were saying. Supporters of the death penalty didn’t even have to say a word. I could be right about that or I could be wrong about that, but that was the impression that I got.

This sort of frustration is how I always feel about nutrition-boosters. I can’t tell you how many discussions I’ve gotten into where I’ve been tut-tutted for liking some food, been told how awful it is for me in terms of fat and lack of nutrients, then listed the nutritional information off the top of my head. Yes, for foods I eat frequently, I remember these things. Turkey pepperoni, for instance, is not appreciably worse for me fat-wise or calorie-wise than sliced turkey on a sandwich. No, it’s not completely stripped of its protein (any more than a turkey sandwich). Yes, a salad would be healthier, but the most likely alternative to a turkey pepperoni snack is not a salad but is cheese. Yes, the cheese has more calcium, but it also has a lot more fat… and wasn’t that your original complaint about the turkey pepperoni?

The real problem, I have come to determine, is not so much that I am eating turkey pepperoni or inulin. It’s that I’m not eating what they eat. Now, if I’m asking for advice on how to lose weight, suggesting replacing turkey pepperoni with celery is some darn good advice. And maybe the turkey pepperoni really is bad for me in some way that I can’t measure. But it becomes rather obvious to me that they really don’t care if it is or not. It’s consumer food. Consumer food is evil.

That’s how I feel about a lot of the complaints about unhealthy beef. It’s not that I don’t think that there’s a problem with tainted beef. There is! I want it fixed! In fact, I think that I want it fixed a lot more than the people screaming most loudly about it. For them, it’s like method-X insofar as it is a tool to their ultimate goal of getting me to stop eating beef. As a beef eater, though, I have more of a stake in how healthy or unhealthy the beef I eat is.

I am reminded of this by a post by Marion Nestle, last seen accusing a 20oz Coca-cola drink of having 800 calories, who argues that irradiation isn’t a particularly good idea. Why is it not a good idea? Because killing bacteria lets the industry get away with selling beef without bacteria in it {cue nefarious music}. So she has now demonstrated that E. Coli is really secondary to the evilness of meat producers.

I’m not arguing that meat producers are benevolent entities nor am I denying that they are guilty of all manner of things including gross mistreatment of cattle. Maybe a law should be passed about that. But every other recommendation (mostly involving testing and handling of meat) I’ve read has come across as far less likely to actually reduce bacteria and more likely to make meat more expensive and the industry less profitable. And it becomes ever more apparent to me that the issue has little to do with bacteria at all and more to do with punishing thy enemy and forcing people to eat less beef.

On a relatively unrelated note, I find it fascinating how bacon became at some point the classy, hip meat. Would the above article have been written if the E. Coli had instead been found in bacon? Oh, probably. But there’d probably be fewer people solemnly nodding their head at the notion that Middle Class America Knows Not What It Consumes.

The military is looking at banning smoking in the military. I didn’t really have an opinion until I read the explanation:

Jack Smith, head of the Pentagon’s office of clinical and program policy, says he will recommend that Gates adopt proposals by a federal study that cites rising tobacco use and higher costs for the Pentagon and Department of Veterans Affairs as reasons for the ban.

Now smoking is bad for you for all sorts of reasons. And there are reasons I could see it being particularly bad for soldiers. It cuts into stamina, disrupts sleeping patterns, and so on. And the military is a place where the “freedom to be” does not really exist. So there are a number of reasons as to why I could support (or at least decline to oppose) a ban.

Health care costs, however, are not among them. Soldiers are not like senior citizens on Medicare or less fortunate citizens on Medicaid. They don’t get health care out of the goodness of the hearts of the federal government and its taxpaying benefactors. They get it because they served our country. Just as the GI Bill is not a gift, neither is the VA. If we’re going to put them in harms way and in stressful situations and if they need to smoke to cope with that and we’re not worried about the effect it would have on their job performance, then paying for some emphaczema tanks and lung cancer treatments is really not something that we should get huffy about.