Health insurers shun people with health problems

Here's a personal story -- a single vignette out of countless others -- that shows why the United States needs to reform our screwed-up health care system, pronto.

Earlier I wrote about how we labored to fill out a lengthy on-line Regence BlueCross BlueShield of Oregon application: a request to change our individual coverage from Plus to Premier, since that seemed to fit our needs better.

Yesterday my wife and I got individual letters from Regence. Bottom line: denied. Here's how my letter started out.

Thank you for your application requesting a change to your current coverage.

After carefully reviewing your health application and any available claims history we find that we are unable to honor your request for a change in your coverage based on the following condition(s) and/or symptom(s):

Hyperlipidemia
History of enlarged prostate

Our inability to honor your request for a change is based on the medical history profile, which contains risk factors that fall outside our Individual plan underwriting guidelines. We apply our risk criteria fairly and consistently to all applications we receive for coverage.

Well, this must mean that Regence rejects almost everybody around my age (60) who just has a few minor medical problems, because I'm on the upper end of the healthy bell curve, for sure.

My dreaded "hyperlipidemia" consisted of a one-time total cholesterol reading four years ago of 212, which dropped instantly into the 160's after I started taking a generic low-dose statin, and now sits at 181.

So for one year, according to the American Heart Association, I was at a borderline-high risk level, and now I've settled into the desirable level by taking $10 per month lovastatin.

My other big risk factor, which also popped up in 2005, was a moderately enlarged prostate. At the time, I blogged about my family doctor finding evidence of this via the least enjoyable part of my physical exam.

This was my first prostate exam where I got a running verbal commentary from the doctor: “Hmmmm. Feels pretty normal. Regularly shaped. Just about normal size. Well, let’s make that a normal size for men your age who have a somewhat enlarged prostate.”

Great. A prostate exam is the only time you don’t want to hear from a female who is inspecting your genital area that you’re larger than average. Maybe Flomax will get me nearer to normal.

Which, it did. Along with Avodart, a complimentary drug I started taking a few years later.

And that's the sum total of the medical problems that caused Regence BlueCross BlueShield of Oregon to deem me outside of their underwriting risk factors.

I feel sorry for the many people who are denied coverage completely because of pre-existing conditions, since I was only denied a change to another Regence plan. The ugly truth is this:

Health insurance companies don't want to insure people who aren't healthy.

That, of course, includes almost everyone at one time or another. In 2008, one in five Oregonians who applied for individual health insurance were rejected due to pre-existing conditions. 

Crazy. The private sector of our health care system is dedicated to providing as little health care to people as it can get away with.

To a patient, health care fulfills a need. To the insurer, health care is a cost that detracts from profits.

A MSNBC piece, "When you are denied health insurance," explains that in the 1930s hospitals began offering insurance policies that were fair and affordable.

But commercial insurers, who joined the game in the 1950s, had another obligation: pleasing shareholders. The simplest way to make money was to try to attract healthy customers, who were less likely to rack up big medical bills. That way, insurers could charge lower premiums yet still clear a profit. Excluding sick people wasn't so easy when insurers agreed to cover the employees of a large corporation.

But denying coverage to risky prospects who sought coverage individually was simple. If an applicant had a history of illness, weighed too much or worked in a job that carried greater-than-usual physical risks such as mining or construction, the insurer would charge higher rates or simply refuse coverage. And once a few insurers started screening applicants, the others were forced to follow suit — or chance winding up with all the sickest people, a certain path to bankruptcy. Within a decade, such weeding out of the infirm or those likely to become so was common practice.

So that's how we've arrived at the insane situation where people who need health care, even if they have relatively minor problems, are rejected by private insurance companies. That keeps profit margins up.

And the United States' health ranking down. We spend more of our GNP on health care than any other country, yet the performance of our health system ranks 37th in the world.

People our age, over 60 but under 65, get particularly screwed if they're retired and couldn't continue with an employer-based insurance plan. Which describes us.

I'm suspecting that Regence is eager to get us onto Medicare and off our current policy. So they weren't going to approve our request to move to a different plan, since they'd prefer we didn't have any Regence plan but have to put up with us for another four to five years.

Tomorrow I'm planning to phone Regence and ask some questions about why I was rejected. Check the comments to this post for any updates to our story.

Comments

[Amanda]

My 25 year old daughter was denied coverage because her BMI (body mass index) is too high; she has no health problems.

[Rain]

Your story is an excellent example of why we need to demand our Congress people give us a public option. Without that, they are the foxes guarding the chicken coop and all they care about are profits, no concern for individuals. It's infuriating that Congress is even debating this. The left wing won this election and this is what we want. When the right wing wins, they always say they have a mandate. Well the Congress and President got one in November. They better remember it or we should vote out all in there who vote against it and keep voting that way. You can bet the right does.

[Sam]

I am in my 20s and was denied health coverage because I had tested positive for lyme disease (they failed to take into account that the test was a false-positive, and I never had the disease!!)

[Brian]

Well, I just got off the phone with Regence and our insurance agent. Bottom line: Regence, like other insurance companies, does its best to not accept individuals with health problems -- even minor.

I called the underwriting department. Didn't talk with an actual underwriter, but was told (after being put on hold) what an underwriter said.

Supposedly my application was denied because I have two prescriptions for an enlarged prostate (Avodart and Flomax are complimentary, having different effects).

"You might need surgery in the future," I was told.

"Well, that's news to me," I replied. I've never heard that from my doctor, and my prostate is nicely normal now.

I told the Regence person, "Anything is possible. Anyone might need surgery in the future, or get some unexpected health problem. You guys seem to only want to give health insurance to individuals with no health problems, who have no prospect of having a health problem in the future. That's ridiculous. It isn't the way life goes."

Our agent said that the underwriting criteria are secret, so it is difficult if not impossible to challenge them. However, I might give it a try, though, because I'm so irritated by the irrationality of Regence.

"You have some health problems, so you can't have health insurance." This is why we need to reform our health care systems, and have a robust public option.

[Kari Chisholm]

This absolutely has to change. It's ridiculous.

This is one of the things that Senator Wyden has been fighting to change in the health reform debate. His Healthy Americans Act would explicitly forbid the use of "pre-existing conditions" to either deny coverage or have discriminatory rates.

Under his plan, it wouldn't matter if you're an Olympic athlete in prime condition or a 60-something cancer survivor, you'd get the same coverage at the same price.

Regardless of what you think of the rest of the HAA, his insistence on that point is to be commended.

[Full disclosure: My firm built Senator Wyden's campaign website, but I speak only for myself.]

[tucson]

It is unfortunate that at a time of great need for change in the healthcare system, we simply don't have the money to do it. The U.S is broke and is borrowing money from itself to pay its bills and those of losing corporations.

50 years ago a doctor would show up at your house! with a black bag that contained most anything needed to treat you unless your head had been severed by a chain saw. Now there are so many new technologies, medicines and diagnostic tests that the healthcare system is a victim of its own success.

Many tests and procedures are routinely prescribed even when the patient is not in crucial need of them. This is done partly for profits and partly to cover their asses from lawsuits. So, the insurance companies get shafted by outrageous charges like $5.00 for a single bandaid. Then of course they shaft back with higher premiums and more stringent coverage standards..."You had gas from your mexican dinner last week? Could be impending gastrointestinal disease. Sorry, we can't cover you."

If we shift the cost of all this technology to the government, somebody still has to pay for it and manage it. Why, in light of all the bungling of government and congress do people believe they are going to make a rose out of sow's ear?

Do we really want some beaureaucrat making decisions in our healthcare? In the same way insurance companies deny coverage, some supervisor will decide if you get a test or treatment or not. If you don't fall within the official government parameters, you're screwed and will have to dig out of your own resources and go elsewhere for what you need. This happens in Canada now where people are put on a waiting list for a surgery. Many of them travel to the U.S. to get it because they don't want to wait.

If the 50,000,000 or so people who aren't insured suddenly are insured we still have the same number of doctors. Hmmm, it doesn't take a genius to see that this is not going to translate into shorter waits in the reception area.

I don't have an answer and I think in the coming months we will see no one else has a good solution either. It would be nice if there wasn't a multi trillion dollar debt and deficit to overcome.

At least in the current non-system there is the possibility of treatment when you need it. If you have the resources, you can pay. If not. Too bad. Once again nature reigns supreme. The strong survive.

[Randy]

Italian study on statins

http://www.wellnessresources.com/health/articles/statin_use_speeds_onset_of_coronary_adverse_event_hospitalization

[tucson]

cholesterol myths

http://www.ravnskov.nu/cholesterol.htm

[Robert Paul Howard]

"...Once again nature reigns supreme. The strong survive."

Until they suffer death (as all do/have).

Perhaps the tax on capital-gains ought be raised. Yeah. That's a good way to see how "strong" some folks are. And how well they might be able to continue living by the (asserted) contention that: what is, is. Especially when they might suffer a bit more like those weaker 50,000,000. (Or perhaps there simply is just no compassion for those weakings: let them suffer; let them die in pain.)

Robert Paul Howard

[tucson]

It's not a matter of compassion. You can't save someone from drowning if you're drowning yourself.

[Robert Paul Howard]

Whereas some hope to "save" themselves from "drowning," while letting many others "drown" as the "strong" look after only their own welfare: "The strong survive" thereby in a world of "drowned" corpses.

Ought "the strong" expect "compassion" (or even restraint) from those that encompass them? Perhaps they will meet their "death" by another mode than by "drowning."

They will, after all, all eventually die. What is, is. (Although maybe he who dies with the lowest capital-gains tax rate is the ~winner~. Or not.)

Robert Paul Howard

[tucson]

The government is drowning. It is in no position to finance or administrate the drowning health care system.

Obama’s health care proposal is, in effect, the repeal of the Medicare program as we know it. The elderly will go from being the group with the most access to free medical care to the one with the least access. Indeed, the principal impact of the Obama health care program will be to reduce sharply the medical services the elderly can use. No longer will their every medical need be met, their every medication prescribed, their every need to improve their quality of life answered.

It is so ironic that the elderly - who were so vigilant when Bush proposed to change Social Security - are so relaxed about the Obama health care proposals. Bush’s Social Security plan, which did not cut their benefits at all, aroused the strongest opposition among the elderly. But Obama’s plan, which will totally gut Medicare and replace it with government-managed care and rationing, has elicited little more than a yawn from most senior citizens.

It’s time for the elderly to wake up before it is too late!

An example the consequences the elderly of Canada are feeling from just this kind of program-- Limited colonoscopies have led to a 25% higher rate of colon cancer and a ban on the use of the two best chemotherapies are part of the reason why 42% of Canadians with colon cancer die while 31% of Americans, who have access to these two medications, survive the disease.

Overall, the death rate from cancer in Canada is 16% higher than in the United States and the heart disease mortality rate is 6% above ours’.

Under Obama’s program, there will be a government health insurance company that gets huge subsidies of tax money. It will compete with private insurance plans. But the subsidies will let it undercut the private plans and drive them out of business, leaving only the government plan - a single payer - in effect.

Today, 800,000 doctors struggle to treat adequately the 250 million Americans who have insurance. Obama will add tens of millions more to their caseload with no expansion in the number of doctors or nurses. Indeed, his plan will likely reduce their number by lowering reimbursement rates and imposing bureaucrats above them who will force medical decisions down their throats. Fewer doctors will have to treat more patients. The inevitable result will be rationing.

And it is the elderly who rationing will most effect. Who should get a knee replacement a 40 year old or a 70 year old? Who should get a new hip, a young person or an old person? Who should have priority in the operating room a seventy year old diabetic who needs bypass surgery or a younger person? Obviously, it is the elderly who will get short shrift under his proposal.

But the interest groups that usually speak up for the elderly, particularly AARP, are in Obama’s pocket, hoping to profit from his program by becoming one of its vendors. Just as they backed Bush’s prescription drug plan because they anticipating profiting from it, so they are now helping Obama gut the medical care of their constituents.

It is high time that the elderly of America realized what the stakes are in this vital fight to preserve Medicare as we know it and keep medical care open, accessible, and free to those over 65. It is truly a battle for their very lives.

Brian, aren't you going to be 65 in less than five years? Relief from messing with those pesky insurance application forms is just around the corner, unless...

[Robert Paul Howard]

Dear "tucson,"

Therefore - by this upcoming (?) system - "Once again nature reigns supreme. The strong survive." Opposition to it, therefore, is a contradiction of your earlier premise.

By the way: if "31% of Americans, who have access to these two medications, survive the disease[,]" then 69% of them die. Versus your asserted "42% of Canadians with colon cancer [who] die...." Either you misstated your "facts," or this assertion, too, supports the contrary of your contention.

Robert Paul Howard

[tucson]

You don't like me very much do you RPH?

But your observation is correct and astute. 31% of americans die of the disease not 'live' according to my source.

Regardless of statistical accuracy, the canadian system is not a panacea, not that what Obama proposes is exactly the same. There are countries where the healthcare systems work fairly well but they have much smaller populations, not 300+ million like the U.S., and most importantly they are not broke. The U.S. is broke. Man can't live on fiat currency alone. It is like living on unfortified white bread. Eventually you will die.

[Robert Paul Howard]

Dear "tucson,"

It is regretable that you falsely infer that my differing from your opinions, and/or indicating errors in your contentions, means that I "don't like...[you] very much."

Like your once incorrectly inferring that I was hiding my identity under an alternative name ("Anonymous," I think it was), you have again made another error.

I "like" you much more than some others who comment on Brian's blogs. Even though you do make errors.

Robert Paul Howard

[tucson]

RPH,

You are certainly correct here. I do make errors for which I appologize. Much nuance and tone is lost in the written word and we are frequently misunderstood. "Like" was probably a poor choice of words on my part. Anyway I am glad you 'like' me more than some people on the blog even though that may not be saying much.

[Carla]

Regence also administers the Oregon Medical Insurance Pool, which offers coverage options for anyone who has been denied coverage by Regence or any other carrier. No underwriting is required. You should check it out - you can probably get comparable rates and better coverage.

[Carla]

Also - those terrible underwriters that everyone thinks are just so evil... they're nurses. 80% of applicants are accepted, per state law. If it dips below, the insurance company pays a significant fee that goes to pay for the high risk pool (Oregon Medical Insurance Pool), which brings rates down for those who get denied coverage.

[Brian Hines]

Carla, you've done a good job with the many comments you left on my Regence blog posts as an apologist for Regence. I still stand behind my criticisms of the company, and of private insurance companies in general.

This county spends hugely more on health care than countries with some sort of national health plan, and we get vastly less health in return. The reason is the disorganized, inefficient, wasteful way health care is organized, and health insurance companies are a big part of that.

Just talk to the people in any doctor's office. Or to a psychotherapist, like my wife was for many years (in private practice). Health insurance companies are dedicated to paying as few claims as possible, and authorizing as little health care as possible. That's how they make money: by taking in premiums and not paying out benefits.

You mention the supposed low profit margins of health insurance companies like Regence of Oregon. You didn't mention how many expenses go toward a large bureaucracy of highly paid administrators and less highly paid staff who aren't necessary in single payer health plans, or national health plans that are much more efficiently organized.

Perhaps Regence only makes a small profit, accounting wise. That profit was achieved after paying the large bureaucracy mentioned above, money that we subscribers pay in premiums but never get back in health benefits. This is deeply irritating, along with the double digit premium increases that we pay each year.

As I said in another post (look in the left sidebar for the Google search of this blog and type in "Regence"), Regence's shifting of individual subscribers to their new Evolve plans simply is a hidden way of foisting another double digit premium increase on subscribers. They've reduced benefits while forcing people to get fewer benefits and choose a higher deductible to keep their premium about the same.

Sorry, but the fact is that health insurance companies are standing in the way of better health at lower cost for the American people. The sooner they go the way of the dinosaur, the better: extinct.