HMO's...products of a Political Hypocrite/ funding prosthetics

[Esther]

On Tue, 3 Jul 2001, angelasnow wrote:
> From: angelasnow <angelasnow at optushome.com.au>
> 
> It sounds to me that the US is more like a third world country in the way it
> provides (or doesn't provide) for low income amputees.  It really is
> disgraceful.  Governments have a choice how they spend their money, and if
> the money they spent on, say, election campaigns was channelled into health
> areas, you might see some improvement.  Also, I know this may seem like
> sacrilege, but you guys may need to pay more tax to fund some of these
> health programs.  Americans are one of the lowest taxed nations I believe
> (I'm sure I'll soon be corrected if I'm wrong!).
 
Angela, you have a misconception about campaign spending in the 
USA.  Most of the money spent on election campaigns is not
government money.

As for government-provided health care, I have some experience
with that from the U.S. government.  I was a military dependent
for the first 21 years of my life, and got medical care from
military facilities and through CHAMPUS health insurance.
Military medical care for dependents was very HMO-like then; your child
must have 3 bad ear infections before she qualifies for the waiting
list for inserting tubes in ears - that sort of thing.  What military
health care does for active duty is very different from what it does
for dependents.

As for national health plans, well I have some experience with
England's national health care.  I became an amputee in England in
1970, and lived there until returning to the U.S. in 1972.  The
hospital where I had an emergency amputation done after the
traffic accident did not stock small needles suitable for the
veins of children - they only stocked 2 sizes of needles. This
was involved in permanently damaging a couple of my veins at
age 8 - it saved a whole lot of money didn't it?  My first permanent limb
was delayed over 6 months because the union of prosthetic technicians
went on strike.  I have been suspicious of government involvement in
health care as an adult.

The 50 states in the USA each have a Medicaid program for providing
health and dental care to low income citizens.  What Medicaid will cover
varies from state to state.  I hear that in Canada, what their health care
covers will vary from province to province.  The problem with Medicaid
is that you need to be very low income to qualify for it, and your
state may not cover the health care that you need.  Medicaid generally
covers lifesaving treatment like kidney dialysis and organ transplants,
and there is usually more coverage for children than for adults. An
employed person whose income is above the poverty level mostly does
not qualify for Medicaid, but their children may if they have no
other health insurance available.

For U.S. citizens who are 65 and older, there is Medicare health
insurance.  And you can buy Medicare Supplemental policies, to
cover what Medicare leaves out. A very low income person who is
older than 64 can be covered by both Medicare and Medicaid.  I am 
not in this age group, and I know little about it.

This doesn't cover the Veterans' Administration health care - I
know little about that.

The problems in the USA is that (1) some number of people have no
health insurance; and (2) many health insurance policies have abysmal
coverage for prosthetics.  This is something I have to research
every time I change jobs, or my employer changes insurance.  Insurance
policies tend to have decent coverage for common things like childbirth
and ulcers, and have skimpy coverage for uncommon things, or for chronic
conditions like asthma.  

There was a very common story in the ACA's magazine a couple of years
ago.  An employee of the Social Security Administration (a federal
government employee) had an unexpected serious health problem arise
suddenly, and had to have a leg amputated.  Because he never
suspected that he would need to know what Durable Medical Equipment
was, he had chosen the federal Kaiser HMO health plan.  That particular
plan does not cover prosthetics at all.  Other federal health plans
do, but they have more out of pocket costs.  Other Kaiser HMO plans
cover prosthetics, but not the federal plan.  HMOs in general tend to
have a bunch of conditions or have very small yearly outlay limits.
The uncommon thing about this man's story is that coverage in a small
newspaper and In Motion caused Kaiser to make an exception and pay for
1 prosthesis for this man.  I assume he changed health plans at his next
open season.  A lot of HMOs exclude Durable Medical Equipment, because
it's assumed to be crutches and bedpans - cheap stuff that few people
need, so the few can pay out of pocket, or use a different health
plan.

Fortunately the Health Care Portability Act around 1996 made employer-
provided health plans limit the pre-existing condition crap to 1 year.
Unfortunately, that does not apply to non-employer health plans, and
does not require a health plan to cover every unforeseen type of health
care.

Another problem in the U.S. is state legislation that requires health
plans to offer care for certain things, 1 condition at a time.  First,
many employer-offered health plans are exempt because the employer is
self-insured.  Second, you could spend forever legislating 48 hours
in hospital after c-section, reconstruction after mastectomy, vasectomy
must be covered, oral contraceptives must be covered if viagra is
covered, a plan must not require patient to go to another state for an
organ transplant, etc.  The laundry-list approach could take years
to get to adequate prosthetic coverage, and the law would not apply
to all health plans anyway.

Esther
--  Esther   esther_l at ieee.org    Speaking only for myself.
If you're not part of the solution, you're part of the precipitate.