The State of Public Health Care in the United States

The only way I can tell this story is to share the personal experience of someone I know very well. I can’t pretend to be unemotional about any of this. I’m very emotional about healthcare.

I’m 56 years old, and I grew up in the days before such company-oriented niceties as coordination of benefits and “managed” health care. We got sick, we went to a doctor, and our employers (or our parents’ employers) provided the health insurance that took care of it.

Not having “coordination of benefits” meant that if you had coverage from two companies, both paid. Maybe that is seen now as unfair to the insurance companies, but all it really meant was that each company had to pay what they had contracted to provide, without coordinating with each other to make sure that you didn’t get more than they wanted to pay you.

It’s common enough to have more than one life insurance policy, and we’d be shocked if the various insurers got together to decide how much they should pay your survivors in order to minimize their own responsibilities. We’d be shocked, horrified, and they’d be sued. And they would lose, because each has contracted to insure your life for a certain amount of money. But we take it for granted that health insurance carriers have the right to decide amongst themselves just what our benefits will be.

I know someone who was employed for most of her adult life. That’s meant that she’d had company provided health care for most of her adult life. In fact, one of her jobs was as a referral and authorization coordinator for a major managed health care company.

It was her job to look at your file and make basic decisions on what health care you were entitled to receive. These were basic decisions, usually involving a “rule out” diagnosis and two visits to a specialist. There were always certain conditions that had to be met, and if they weren’t, the case was sent to a nurse for review. Anything beyond the nurses was reviewed by a doctor. The nurses fought for some cases, and some of the fights were lost.

Nurses would end up in tears because a patient they had never met had been refused treatment and had died. I’m not qualified to imply cause and effect here, though it’s tempting. These patients might have received the requested treatment and still died. That’s the reality of medicine in the real world.

Instead, I would say that these were sound business decisions, made by an organization designed to be for profit. I would also have to tell you that while she was working for the company, their CEO was second in this country only to Michael Eisner in salary and perks. Michael Eisner was running Disney, an entertainment company. The medical insurance company CEO was running a business that had responsibility for safeguarding people’s lives.

She moved on from that company, but not before being diagnosed with heart problems and what would later turn out to be fibromyalgia. A couple of years later, she married and left the work force to care for her new husband, who was partially disabled and needed her help in order to be able to work full time.

Her new husband’s employer provided them with health coverage. It was HMO care, and they sometimes spent half a day sitting in a waiting room, but at least they had care from doctors and pharmacists they respected and could communicate with. Of course she didn’t have a cardiologist for most of that time, because the HMO didn’t include a cardiologist that her PCP (primary care physician) trusted. Ditto for a dermatologist. Ditto for a podiatrist. And the same for an orthopedic surgeon and a psychiatrist. And no neurologist or endocrinologist for her husband. Still, their overworked PCP’s managed to keep their conditions under control.

Eventually, her husband’s job went south, and so did their health care. And then, so did her marriage. She ended up moving back in with her parents at the age of 50, with no health and no health coverage. She was unable to get out of bed for the first month she was there. It took her 6 months to track down the county version of the health care she needed. This is what is known generically as Medicaid, although it has different names in every state and/or county. We both find it hysterically funny that in her county she’s considered a medically indigent adult, or MIA.

Medicaid is paid for by the federal government, but administered by the states and counties. She had good documentation for her conditions, in part because she was already halfway through the process of applying for Social Security disability. So, it only took her about 4 months to get back on the meds she needed. The meds that one of her former physicians had described as, “…the ones that keep you alive, and the ones that keep you taking the first ones.”

She was eventually denied SSD after three appeals. That was a call made by a state paid doctor who was contracted by the SSA to dismiss as many claims as possible. I say it that baldly because there was a court case in which they found that that was exactly what happened. Unfortunately, by the time it was discovered, she had fallen through the cracks.

So, she has done whatever she could do to earn enough money on her own (from home) to supplement her family income so that they don’t starve. Yes, I mean literally. There have been weeks they’ve lived on potatoes. Thank God for loyal friends and family, who frequently have made the difference for them between sinking and treading water.

A side bar here about some of the ways the system works. She takes Prozac, an antidepressant. That, of course, is a psychiatric drug. It was prescribed for her in the first place by her PCP almost 10 years ago. She takes it religiously, one might say, and she almost jokingly says they would have to pry it from her cold, dead hands. She had been on the same dose (with great success) for almost 4 years when she moved and became a county patient.

Now, you have to understand that she has seldom seen a doctor here, perhaps three times in 5 years. She sees PA’s and NP’s, and other alphabet soup practitioners, most of them extremely competent, some of them quite the opposite. But one thing they all took for granted from the first was the list of prescriptions and dosages she told them she had been on. With no argument and little examination, they duplicated the prescriptions as she described them, including pain meds.

Except for the Prozac, which she takes for long term clinical depression and PTSD. That had to be prescribed by a psychiatrist. Which is fine and good, and makes sense. Except for one thing. In order to be eligible for county physical health care, one cannot be receiving, or have applied for, Social Security benefits. She was coached about what to say by the intake people before she ever applied for the care. It was that or not have the drugs she needed to survive, so she did it.

Funny thing though. In order to qualify for county mental health care, she had to be receiving, or have applied for, Social Security benefits. The extremely nice people at the mental health office knew she was just there to get the prescription written, in order for the other office to REwrite it. They carefully and tactfully guided her through filling out those county forms so she could get the care she needed.

You got that, right? In order to qualify for county physical health care, you cannot be receiving Social Security benefits. In order to qualify for county mental health care, you must be receiving Social Security benefits. To make it more interesting, the county mental health care system has no budget for outpatient meds. So, the only way to get the prescription filled is to have it rewritten and filled by the county physical health care system. Huh?!

Now, we’re talking about someone who doesn’t know from one day to the next if she’ll be able to get out of bed. She never has a day without pain and some degree of exhaustion. Her ex-husband is in better physical shape and is currently receiving SSD benefits. Last time she checked with a lawyer she was told that because she hasn’t worked for wages in more than 10 years, she would probably be turned down again if she reapplied.

So, she works under the table, stays in bed when she must, and basically exists as a non-person. She is working to fix that, going back to school online with the eventual goal of being a gainfully employed lawyer, even if she will be in her 60’s. It will take her about 5 years to complete her BA and finish law school, and she can do it all online.

After the story you’ve just read, do you wonder what her specialty will be? And guess what her primary issue is in the current election.

This is the United States of America. We can do better. And we should. And we should be ashamed that we don’t.