Demystifying Health Insurance

Health insurance is a big scary topic in the US, and one that leads many people to just back away.

Coverage tends to be very complicated in this country and feel overwhelming for everyone who could, should, or might get health insurance.

For those of us in the disabled community, health insurance tends to be even more of a necessity than it is for abled people, as we generally need to use it often.

Let’s look at it more closely and discuss what health insurance really is(and isn’t) and just what we can do as a community and society to improve it.

Health Insurance, at its most basic, is a gamble

Like most forms of insurance, the basic idea is that clients pay the provider money on a regular basis to protect their investment. In turn, the provider promises to reimburse/pay/support the client if their investment is damaged or needs their particular form of protection.

With health insurance in particular, the client(you) pays the provider a monthly fee(premium) in order for them to help you protect your health. They are responsible for paying for a percentage of your health care costs based upon the plan you choose.

You are paying the premium so that if you have a medical need, they will reduce the cost you would otherwise pay. Your goal is to end up paying less for the services you need plus the premium than you would pay if you had the medical need with no insurance.

The other aspect is that it’s supposed to give you peace of mind that should something go wrong with your health, you won’t need to worry about those expenses.

They are betting that out of all the clients they have, on average they will bring in more money than they spend on their clients.

The power of the pool

All the clients that are in a particular plan(or helped by a particular provider) is their pool of clients. The size and health of their pool of clients greatly influence how much money they are likely to make, with the other major variable being how much money their clients provide them.

The larger and more diverse your pool of clients, the more likely it is that they will have varied health care needs, and the greater the likelihood that, on average, the payout per person will be less.

This is the underlying argument for some form of universal health care, such as Medicare for all.

If healthy people are paying the same premium as disabled people, and the pool of the plan includes everybody in the country, then the average cost for care will be relatively low.

The way things are currently set up, we have many small pools spread across the country, and each one of those is doing its best to leave out disabled people, or make their paperwork so complicated that we don’t fully use the available benefits.

Also, when it comes to creating deals or building networks, the more people in a provider’s pool, the more power they have when it comes to negotiating prices with drug companies and other healthcare providers. One pool of everybody in the country has more bargaining power than the hundreds of small pools that exist today.

Most countries run some form of universal health care plan, where citizens pay additional taxes to have health care coverage from cradle to grave. When costs are compared to the current costs of the current health care systems in the US, we are paying considerably more for, on average, much worse outcomes.

Why is healthcare so expensive in the US?

Those of us who have health insurance are basically paying for fewer options with greater expenses because each insurance provider is bidding against the other to form each network.

There also is a lot of money paid to the middlemen of the process, which simply don’t exist in countries with national insurance plans.

With all the competition, each company has opportunities to create bidding wars, create strategic partnerships that don’t necessarily benefit the consumer, and create mountains of paperwork that people need to be paid to process.

Also, uninsured people do also need care, and because they aren’t part of any network, they are usually charged exorbitant prices, and often can only go to emergency rooms, which tends to increase the costs of their care and lead to longer waits before they get care.

These long waits often mean that when they are seen, their medical needs are more complicated(and expensive) than preventative care would have been.

The complications of so many choices

Health Insurance companies also are actively working to reduce their expenses.

The Affordable Care Act helped protect disabled people through some actions(like ending pre-existing condition clauses), but insurance companies have responded by creating a confusing plethora of plans that make it almost impossible for anyone to completely understand their options.

At this point, the main reason that there are so many different insurance plans seems to be that it allows the insurance companies to confuse their clients and either create additional charges or create additional delays in their client’s coverage.

Most employers provide two to five plans for their full-time employees, from one or more health insurance providers. For couples where both are working full-time, that means they may be choosing among up to 10 different plans by multiple different providers. That’s a lot to compare.

There also are very few spaces where you can get education into understanding health insurance plans, other than from the health insurance companies themselves, who tend to provide bias towards their plans in the information they provide.

While there are some organizations that purport to help you select your plan, many of them are also paid by a particular network to bias the individuals they talk to towards one particular company over another – or those staffs are poorly trained in the details of the plan options.

I remember reaching out to a network recommended by Walgreens, and being told I could still use my Medicare card while on Medicare Advantage. If I had done so, it would have been considered fraud.

It’s no wonder that most people get anxious or overwhelmed when it comes to selecting their health insurance plan.

The additional costs we pay for our current healthcare system

As disabled people, we are subject to bias from the healthcare community. This makes every step of the process more difficult.

Generally, to get better coverage, you need to pay a higher premium.

These high premium plans are harder to afford on a limited budget, and so require us to make sacrifices in other areas of our lives – or price us out of the plans that we need, leading to us paying more out of pocket each month for less-effective coverage.

If we go without necessary care, we risk becoming more disabled and losing our ability to work more quickly.

Many of us with disabilities end up on either Medicare(if we’re lucky and get SSDI) or Medicaid(on SSI or if we’re poor enough).

The good news about Medicare is that the basic coverage is pretty decent, and generally, we just need to select the medication plan(Part D) that makes the most sense for us.

Selecting medication coverage is a bit easier than selecting every portion of a plan.

However, there are also Medicare Advantage plans as well. They have the same premium as regular Medicare, but the money is paid to the major insurance company that offers the plan.

While some people find these plans beneficial, and they do often cover dental and vision care(which Original Medicare does not) while also covering medication(replacing part D), often these plans are advertised in a predatory way and can be a much worse option for the consumer.

Many states that provide Medicaid coverage have also made a shift to working with the same major health insurance companies.

Rather than having an “original Medicaid” program, you often are assigned an HMO that manages your Medicaid care.

What many people on Medicaid don’t always realize is that they can switch their HMO during their open enrollment period.

If you are on Medicaid, I encourage you to find out when your open enrollment period is so you can choose a plan that best suits your needs.

With so many plans out there, run by multiple companies, and with them being so very confusing to choose between, one of the biggest things is that they all seem to have somewhat dubious customer service.

Getting the information or support you need can involve multiple phone calls, being redirected through multiple call centers, explaining the situation multiple times – and no guarantee that you’ll come out with a solution at the end.

The poor customer service and complicated process makes it harder for us to use or fully understand our benefits, and since most insurance companies seem to be similarly challenging, there doesn’t tend to be a simple alternative.

Health insurance is overly complicated, and intentionally so.

How to take care of yourself when the healthcare system is broken

Okay, so the system is broken, and you’re going to struggle with it.

You’re already managing a pretty full plate with your disability and all the stresses that accompany that.

So take a deep breath, and first off, know that you’re not alone.

Even financial and health care experts find selecting a healthcare plan stressful and challenging.

This process isn’t easy for anybody. Period.

All you can do is your best.

Focus on what’s important for you.

Do you have a medication that’s often expensive and really helping you?

Do you have a particular doctor, hospital, or medical group that you know, like and trust?

Focus on priorities like that, and make sure that your plan lets you keep them.

Set aside time to pick your plan, and calculate what your big expenses would actually be with each plan.

You don’t need the precise number, just an estimate – but go through the same process with the same base estimate for each plan. See how they are different, and where they are similar.

When in doubt, lean towards the plan that gives you more options.

If you have somebody who shares in this decision-making process, make sure that the two of you(or however many of you there are) take some time to look at those needs and possibilities and discuss priorities.

Do your best to stay calm during the process and look at things logically.

Since you are dealing with your condition, you likely have a sense of what help you need and what your priorities are. Use that to help you find the plan that’s most likely to help you.

And then, when you do select your plan – remember that you can change it next year if you need to – and that even the experts can make mistakes.

You deserve to feel confident about your healthcare choices. And your health insurance often impacts all your options for the next year.

If you’re still feeling overwhelmed, let me help you consider your options.