Health insurance fairy tale

Once upon a time, in a kingdom far away, there lived a happy little group of people in a nice little village in a lovely setting.

(Photo Source: Flickr, Donna Cymek)

These people worked together in the community, each performing some role.  Some people were particularly skilled in one thing, other people possessed another set of skills.  They each earned a decent income working in this community and paid sums of money each month (let's call them premiums) into an account from which members of the community would draw in time of need, medically speaking.

One group was assigned to manage this account.  Over time, they saw that there was generally money left over, which they would pocket.  They liked having not just a salary for managing the account, but also having high profit margins.  Let's, just for the sake of convenience, call this group who manages these premiums for the health maintenance of the happy community: Aetna.

Aetna did a good job for many years; the people in the community were well-cared for and as long as they paid their premiums, had reasonably low expenses for the medical benefits they needed

The community was happy and prospered.

One day, Aetna found out that some people in the community were talking about having a central representative body govern over this health care account.  Aetna became angry.  On top of that, Aetna hadn't pocketed much money the last year.  In fact, they had to pay out more than was paid in (for the first time).  If you were to total all the years they made a profit it would balance out in their favor, but that's not how Aetna saw it.

(Photo Source:  Berlin 07: Angry Fish At The KaDeWe.)

So, angry Aetna decided, due to both concerns, to raise premiums on the community, making each member of the group pay significantly more for the health care account and benefits.  At the same time, they also decided to establish new rules and limitations on what the people of the community could do with the money from this account and how much they could take out.

The people of this once happy community were not pleased by these changes and asked Aetna to reconsider.  Aetna gave a few minor concessions, just to shut the people up, and continued on its merry way, pocketing large profits and rendering fewer services.


Did Aetna know that these actions served only to make people more serious about forming some sort of representative body to govern over the health care account?  Perhaps Aetna didn't really care: get as much money as possible as long as possible.

Meanwhile, some members of the once happy community were hit with hard times financially.  They cut corners and worked hard just to make ends meet.  The higher health care costs and lower benefits provided by Aetna really make things tough for these citizens.  For whatever reason, they had health issues that made them very much in need of medical care and medications  As it became harder and harder for these people to pay their medical bills, they became even more marginalized.  not only did they have medical conditions that affected their day to day lives, but now they were paying enormous sums just for what had once been considered standard care, rendering them now unable to live their lives as "normal" people.  Those people graced by good health went along their merry way; the people with health conditions scrimped and saved and struggled to make ends meet.  They knew of course, that some people who didn't happen to live in the community had no access to any health account whatsoever (not even under severe conditions) so they felt badly  about bemoaning their own state of affairs.

Aetna cared little for the people external to the community without health care or even those in the community who had medical conditions.  They apparently just felt that as long as they could stay profitable, they would continue to play the game, raising the stakes everywhere they could so that they milked the community as long as possible.

The End.

(Photo Source: Standard Rights Managed (RM) BE037954,  Illustrated Political Cartoon: Corporate Greed as Octopus Original caption: 6/27/1882 - Corporate greed octopus gobbles up freight for Great Railroad while unemployed handlers look on. Cartoon 1882. IMAGE: © Bettmann/CORBIS)

Raising health care costs: Researching options

What to do after you find out that your health insurance benefits will cost more and provide you less:

• Step one: Panic. Feel badly about panicking because after all you have insurance and a job which puts you in a pretty good position these days in relative terms. 
  
• Step two: Research, ad nauseum, how much more you will be spending.
• Step three: Panic as you realize that you will be paying the equivalent of a pretty pricey new car loan for the same benefits you had the previous year.
• Step four: Review your budget and see what costs you can trim. 
• Step five: Panic as you realize that you can trim a little here or there but it won't add up to the amount you will now have to shell out just to be medicated.
• Step six: Think about trading in the car for some cheap piece of junk?  Price pieces of junk and get depressed at the thought of having to drive one.
  
• Step seven: sink into a deep depression as the reality hits you that you will never have nice things; your health care costs will go up and up and you will be cutting corners and scrimping and saving forever.
• Step eight: talk to HR and see if they have any ideas.
• Step nine: Panic as you realize that they have no ideas and really just want you to go away; they don't understand what it's like to have rare disorders for which expensive medications are required.
• Step ten: Research what medications might work for your conditions that would be in category one or two.
  
• Step eleven: make appointments with your doctors.
• Step twelve: Look for jobs with higher salaries.
• Step thirteen: Fall into a sea of despair as you realize there isn't exactly a plethora of jobs and even if you got an offer for a good one, whose to say those health care benefits wouldn't also now be inadequate.
  
• Step fourteen: Review your budget again; isn't there any way to cut costs?
• Step fifteen: Panic.
  

The "Open Season" health care surprise

Many companies that offer health insurance to their employees have "Open Season" around this time: typically some window of weeks during November/December.

Open season is the time when the HR folks at a given company unveil the changes in benefits/cost to employees and allow them to consider what types of plans they will sign up for.   Many people have little in terms of options, but if you work for a big company, you probably can choose between a couple plans (with dental maybe or hmo versus non-HMO, maybe also a health care spending account?).

Ok, first of all, let me say upfront: I am going to bitch.  I am going to express my utter despair and sense of frustration.  That said: i know i am lucky to have any health care options (however ill-suited they may now be for me); there are people who are unemployed, self-employed, or employed by companies who offer nothing.  There are families who can't afford even basic care for their children.  I know this and I am not insensitive to their plight; our health care system is broken.  i wish i had a solution for them.

So, why am i starting another blog when the blogosphere is so over-crowded already?

I have a great job; the income is on the low end of competitive, but that was off-set with terrific benefits (including health insurance and sick leave etc--things very important if you like me, have some medical conditions.) So even when i was told that i might be able to get a job with higher earning potential, i stuck with my company.  Now, even though they still offer benefits likely better than most packages, i find myself facing a difficult future.  In these hard times, I am of course happy to have a job.  i never forget that.

Ok, so someone asked me yesterday: "You're telling me that a PhD with a good, stable, well-paying job with good health insurance won't be able to afford her medications?"

Yes. 

The succinct version of the story is as follows:  Aetna told the HR folks where I work that they were discontinuing their PPO plan we had; we now will have a POS (they say that means "Point of Service," but in my view it means "Piece of Sh...")  The big changes are in price and benefits.  Apparently this isn't just Aetna or my company.  Across the board, in response to rising costs and the health care debate, major insurance companies are hiking prices and changing benefits.  It's part of a trend.  This year, prices are higher and benefits have been trimmed; next year the hike will be more steep with even lower benefits.

Many people will not really feel the pinch this year.  Next year, the size of the pool of insured feeling the pnch will increase. 

In my case, it's not just a pinch.

In addition to a steep increase in monthly premiums, the copays will be higher, as will the deductible.  Ok, big deal.  That's not really the source of my financial pain.  My issue is with pharmacy benefits.   Again, trying to be succinct:  there are generally three or maybe four categories that insurance companies place medications in.  These categories determine how much the patients have to pay for their prescribed medications.  Category one, the cheapest, are of course the generic (that's what the insurance companies prefer people to take); next are what they call Formulary drugs (which means they are on a list of acceptable medications; insurees will pay probably double for these drugs when compared with generic prices.)  Non-formulary is category three:  these are drugs the insurance company really wishes insurees wouldn't take; they are often not available in generic form; they are often expensive; they are often not the standard meds most people take.  If there's a category four it's meds requiring special authorization or something like that.

I guess i am lucky.  I have been diagnosed with a number of rare conditions for which I am prescribed category 3 drugs.  I have tried other medications (that would be in category one or two), but the doctors have determined that the best drugs to treat the conditions in my case happen to be drugs without generics (at least not with generic versions available to consumers.)

So, in terms of cost: i will go from approximately $70 a month for prescriptions to $500. That's not even factoring in the increases in premiums, copays etc.

So, without going into specifics, I can't squeeze out an extra $470 from my budget.  I can't move somewhere cheaper because my home (purchased in Sept 2007) is worth less than i owe.  I am making the payments and hoping to get out from underneath it eventually, but i can't just move.   I already watch my expenses and pay off credit cards each month (I am not really very extravagant.)  i can't get a second job because, well, with a sleep disorder i am lucky if i have enough energy to do a full time job and maintain the household.  (and that's with my category three medication.)

So, i tried to find a supplemental pharmacy insurance that might, coupled with my current Aetna insurance, help with the increase in costs.  I found nothing that wasn't either exclusive to AARP members or Canadians.

With preexisting conditions, I can't switch to a new insurance company.

If another option were offered through my work where the costs were higher but the coverage was more like it was in 2009, i would take it in a heart beat, but that's not an option either.

So, basically, I have several rare conditions (oh and in late November I am scheduled to see a hematologist because the docs think i have yet another rare condition to add to the list) for which i take medications.  I take the medications in order to be able to function in my demanding job at levels that meet my bosses' expectations.  i know it sounds improbable.  believe me, there's not a day when i don't think: how could i have several rare disorders?  They must be linked in some systemic way--but unfortunately i didn't study medicine so all i can do is try to read medical journals and reports etc.  Most doctors don't really practice medicine in a systemic way.

If someone happens upon this blog who either has similar problems, please share your story;  if someone has ideas abut what people like me can do, please share them.

I am still exploring and researching and will post more as I have more information.