'It's a money game to them':son takes on UnitedHealth over elderly father's care
theguardian.com
theguardian.com
My wife had an issue with her eye that was giving similar symptoms to macular degeneration [1] in 2016. I had insurance (it might have even been UHC, but I'm not 100% sure), so we went to an ophthalmologist's office, to get it looked at.
When we get to the office, we find out that just the copay for this was going to be $550. I was kind of crap at saving money back then, and I had a job that didn't pay great, and I remember I had exactly $578.23 in my bank account at the time, and I still needed to pay my rent. I had to kind of awkwardly tell my wife "sorry, we don't have the money to have your eye looked at and pay our rent", so we leave without her getting any treatment.
About 4-5 months later, I got a better job with much better health insurance, so she went to that same ophthalmologist, and our copay was less than $50. The entirety of the work that this ophthalmologist did was refer her to a retinal specialist.
This means that I was initially going to have paid more than $500 just to get a god damned referral, and just to re-emphasize this, we had health insurance.
I remember how upset and frustrated I was with that entire situation; it felt like I was doing things the "right" way by getting a desk job with health insurance and yet I still couldn't afford to get the treatment that my wife needed. It just felt...unfair? Like what exactly was I supposed to do differently here?
It didn't really "change" my perspective on this, I had already been in favor of moving to a universal healthcare system, but this thoroughly solidified my perspective on it.
[1] Fortunately, it wasn't that, it was an autoimmune thing. Still not great but better than we initially thought.
Critics of socialized healthcare often point at things like waiting too long for specialists, or understaffed hospitals, presenting them as inherent to socialized medicine itself when it's more often the product of elected officials who simply don't think socialized healthcare deserves adequate funding, or are against the idea of socialized healthcare entirely. Politicians will often piss in your cup and insist to you it's champagne.
There is, of course, the economic arguments around public vs. private health-care systems; but there are also the philosophical, moral, and ethical, arguments regardless of economics. Some things are expensive and yet we still understand they are a good and humane thing to do.
I think this is often a sticking point for agreement. It is hard to get buy in without some level of guardrails on cost and impact. I dont want to bet my house, retirement, and children's future on the promise socialized healthcare will be a net savings for both the public and for me.
For this reason, I think opt-in Medicare is a reasonable middle path, where governments can demonstrate the cost reductions and care, allowing people to voluntarily convert at their own pace.
This would go a long way do dealing with the risk aversion, but I think many people ostensibly for socialized healthcare are too scared test if it could actually compete on price and value.
One of the major selling points is that universal healthcare would provide everyone the efficient administration and low costs of Medicare.
Surely a $550 copay for referral would still be frustrating if it was charged by the government.
Hopefully your wife's vision is not getting worse too fast, autoimmune sounds bad still, as someone with normal vision. Losing your eyesight is terrifying, in my opinion.
Tying health insurance to your job has to be one of the worst parts of the American system.
https://www.icare-world.com/us/products/#perimeters
It was interesting work in terms of the tech, but pretty sad stuff learning to the doctors come in to present information about the pathologies involved.
> Tying health insurance to your job has to be one of the worst parts of the American system.
Yeah, it gives companies so much more power than they really deserve. Not only can they cut off my income supply, which is more or less the nominal agreement we have as part of the capitalist transaction, but they also get to decide if I (or any of my dependents) get to get treatment for any kind of illness.
The medicaid system in the US is actually not too bad, I was really grateful for that in the tail end of 2023 and beginning of 2024 when I was unemployed, but it's extremely concerning that (SOME UNNAMED POLITICIANS THAT I WON'T NAME BECAUSE I DON'T WANT TO BE FLAGGED BY SOMEONE WHO THINKS THAT BRINGING UP POLITICS IS SOMEHOW OUT OF THE SCOPE OF HN) want to drastically cut that program.
It's certainly better to have COBRA, and it does reduce the power that companies have over your health, but it's not a silver bullet.
[1] I won't say which company I was working for but it's not hard to find my work history if you want to make sure which companies to avoid in the future.
Insurance has also skyrocketed the cost of care, I was doing a weekly physio/massage visit and with good health insurance it was a $50 copay. I looked back at what the place was charging my insurance and it was ludicrous. They were billing my insurance $400-600 a week and every little thing they did was getting charged. All the cool like "extras" I thought they were doing for me were becoming $50-200 charges.
I partially tore my achilles last year and most doctors I saw just wanted to check all the boxes so they could send a massive bill to my insurance. I ended up seeing 3 different doctors, a physical therapist and a physiotherapist before I finally found someone who really cared about helping me. It was $2000 out of pocket but he really went all out mapping my recovery and performing all kinds of interventions.
I am scared that universal healthcare would introduce so much bureaucracy that doctors will just process you asap, check off their forms and then shuffle you off. It feels like we are getting further and further from the world where you know your doctor and they can say something like "you only needed a referral, lets just call this $40, see ya in a few months". Now it is someone you may never see again, who has no control over how much you are billed and who has 20 more patients coming in behind you.
I hear this a lot, but that doesn't really seem to be what the data says? There have been a good number of studies comparing American healthcare to more socialized systems, and the outcomes are generally comparable or better in the socialized systems. That doesn't imply that if we just changed to a universal system tomorrow that we would have the same outcomes, every country is different, and it's not necessarily guaranteed that copying Sweden's system would automatically work here.
But I do think that it's also not implied that it would lead to the bureaucratic chop-shop that people are afraid of.
I do think it'd be better if everyone had healthcare and it sucked a little vs "some people have good healthcare while others have none", but of course that's a much harder sell.
The US seems to have real problems with regulatory capture (especially with recent political happenings where we're seeing tariffs implemented that specifically hurt competitors to those with influence in government) so I think it's important to not fall into a trap of believing you'd walk away with a wonderful healthcare system even if something like medicare for all happened. The entrenched interests would continue to exact their pounds of flesh unless a real sea change was seen away from the current status quo.
I do hope it happens though, I'm a Canadian and my employment is dependent on your system continuing as an entangled morass but I'd happily be out of a job if it meant more equitable access to care.
I use the NHS in the UK and it isn't especially bureaucratic, much less so that the US system. It does have its failings though like wait times to get stuff done, poor communication and the like.
That wouldn't be a change.
A universal health care insurance plan, like "Medicare For All," would simplify bureaucracy. How many times can you honestly say that a government run program would simplify bureacracy?! Not often! But if we could just start over, a single health insurance plan that works the same for everybody in the country would be a huge burden lifted.
A Fortune 500 company will find it easier to negotiate a good plan with easier money for it's employees typically, but a mom and pop shop doesn't have the negotiation power to make the insurance companies pay out.
And just because it's a benefit today, doesn't mean DOGE (or whoever next in power) will enshittify it.
There's COBRA for that! If you quit your job, you can continue your previous employer's coverage for up to 18 months, but you'll have to pay the premiums yourself.
And it's typically cheaper than what is available on exchanges. You can also get a subsidy for COBRA if you can't pay premiums, but only if you were fired.
> I am scared that universal healthcare would introduce so much bureaucracy that doctors will just process you asap, check off their forms and then shuffle you off.
We have universal healthcare: Medicare and Medicaid.
With what money?
> We have universal healthcare: Medicare and Medicaid.
Do you know what "universal" means? Both of those programs have significant restrictions on who can access them.
That's not really a consolation if the premiums are really expensive.
> And it's typically cheaper than what is available on exchanges. You can also get a subsidy for COBRA if you can't pay premiums, but only if you were fired.
"Typically" yes, but not always. I mentioned in a sibling thread that when I was fired from a job and was on COBRA, the premiums were almost 4 grand a month.
It was so expensive that I actually started calling up different insurance companies in the NYC area, because the premiums were slightly lower even just paying out of pocket, and luckily I narrowly qualified for a medicaid thing, and it ended up being free through the MetroPlus network [1], so it all worked out, but my point is that COBRA isn't always cheap.
> We have universal healthcare: Medicare and Medicaid.
Medicare and Medicaid are great programs, I'm very glad they exist, I think it would be horrible if they were taken away. That said, they're not "universal" healthcare. It's pretty easy to fall through the gaps where you're "too rich for Medicaid" but "too young for Medicare".
Anecdata, but my brother in law does work for a living, as does his wife, and together they end up making somewhere around $75,000/year in Texas. Not a terrible wage, people have certainly lived on a lot less, but neither of their jobs have health insurance, and they make too much together to get it for free from the state.
[1] If you ever get fired in NYC, I'm sorry to hear that, but do not hesitate to call MetroPlus. The agents there was extremely nice, helpful, and without an ounce of sarcasm I think that their existence makes the world a better place.
It's just "above income threshold between ages of 18 to 65" that isn't covered.
We just need to get the social/political will to fill the bathtub.
That sounds illegal. They have to charge the same premiums that the employer pays. Unless you had a really expensive coverage.
> It's pretty easy to fall through the gaps where you're "too rich for Medicaid" but "too young for Medicare".
I'm sorry, I meant that they are examples of universal healthcare that exists in the US, with some conditions.
Also, and I don’t know how the legality of this, it got progressively more expensive each month. The first month was around $1800, the next $2500, the next $3100, etc.
What's this about getting a COBRA subsidy if you're fired? Where did you hear that?
It just goes to show, aside from the few who keep beating the drum about this, Bernie Sanders, etc. this is just another issue that shows how the people in political power aren't there for you or me, they're there for their billionaire friends.
I lived in Hong Kong for a while. In Hong Kong:
(1) If you want to see a doctor, you just pay cash. Fees are reasonable. (~$50-80 for a GP up to $350-400 for a top specialist.)
(2) There's no other way to pay. (If you have insurance, they might reimburse you later.)
(3) You don't need referrals for anything. (If you need to see a specialist, you call a specialist directly and make an appointment. Many of them will see you on the same day you book an appointment.)
(4) You don't need a prescription for just about anything. (Antibiotics and steroids -- and all the the most powerful non-recreational drugs -- are available OTC.)
(5) ERs, emergency services, and things like childbirth are covered by the government, but the service is generally worse than you'd get if you pay out of pocket.
The US system isn't more "capitalist" -- it's captured by special interests and middlemen to a mind boggling extent. And you don't necessarily need "socialized" healthcare -- you need a system that gives both patients and doctors more agency.
But... The amount of money I spent on medical care in Hong Kong, per year, was probably 1/10th of what I'd have to spend on medical insurance alone if I were in the US. Because patients and practitioners have more agency, and because pricing is transparent, there's actual competition in the market.
Sure, you need money, but it's less than you think, and there are fewer hoops to jump through, fewer roadblocks to treatment.
The optimal system is probably something like that. A public system for emergencies, child delivery, and absolutely necessary treatments -- and a transparent, open, private system for everything else.
13% of the people don’t have a usual place to get healthcare in the U.S.
Correct. Either a person has the dollars to pay or they don’t.
> What is true is that there are lots of people who think they are “middle class” who can’t afford access to the system.
What people think doesn’t really matter when the bill arrives. We might be better off thinking in terms of “qualifies for financial assistance”. Those who have just enough income to disqualify them from assistance will have more trouble paying, obviously. Some of those will forgo or delay treatment due to cost concerns.
it’s people with means who can’t afford healthcare
IMO antibiotics and antibiotic resistance are one of the strongest arguments in favor of gating certain medications behind a prescription.
You can get something sort of like that here in the US - direct primary care. I pay ~$125 per month to my doctor. This can be paid from an HSA/FSA as well. It is not as expensive as "concierge health care", but you get most of the perks and immediate access.
Appointments are usually available next day or even same day - as many times as I want. No co-pays. The doctor has far fewer patients so you can actually talk to them for an hour or two during your appointment. They can charge insurance (if you have it) for most lab-work or you can pay them reasonable rates out of pocket.
They can refer you to specialists if necessary (who may require insurance), or even consult with specialists with your permission, at no extra cost.
The on-going care/prevention aspect will probably help save money and keep me healthier in the long run as well.
But there’s a whole other group that hasn’t had that friction yet, are lucky enough to have the “good insurance”, are completely naive, and/or just buying into the lie that this is all normal and what’s best for everyone. This group reads your comment and thinks “you just want me to pay for something because you can’t afford it” which is a very flawed take.
It can be challenging to get them to believe that it's $3,600/month on the open market in my area for a family of four.
so we went to an ophthalmologist's office, to get it looked at
In UK, you can’t just go to ophthalmologist’s office. You’d first need to schedule an appointment with your GP, who then would (or would not) give you a referral to a specialist. You then need to wait for something between 6-12 months (sometimes more, depending on your location) for an ophthalmologist appointment. You wouldn’t need to pay for it out of pocket, but you’d wish you had an option to pay the damn 500 quid so that you can start the treatment sooner.
Also, I hear lots of horror stories about wait-times in universal healthcare systems, but that always seems have smuggled in the premise of "you don't have wait times like this in the US", which has certainly not been my experience.
I wanted to see an allergist in 2022, so I went to my health insurance portal, and called a few in the area, and the earliest appointment that I could find was almost four months out. My wife had to wait for months even from our good insurance to get approved for proper medication for her eye problem. What insurance do you have where you're not stuck with long bureaucratic waiting lists?
Double irony is the govt healthcare programs seem to be paying/performing better than the privates (Medicare is like the perfect PPO and no wait, managed medicaid/medical used to be sloooooow but now seem to be improving as the in-network provider availability is improving)
they can refer in the same way an NHS GP can, and you can normally get a same week appointment
(obviously you pay for it)
generally the NHS is fantastic once you've been placed on the correct conveyor in the factory
however getting to that point can be an absolutely dreadful experience
I don't know how you fix this problem
That said, it seems like having "free" competition would make it so that the private costs don't get crazy?
Wait times are not exclusive to social insurance at all and insurance networks only further complicate matching supply and demand.
The family friend patiently explained all of the things I take for granted in America, such as being able to choose my own specialists, getting a long list of treatments that were very difficult to get approved in their country (ADHD medications, for example), and the ability to shop around for shorter wait times.
Really opened my eyes to the tradeoffs that come with different systems, whereas the Reddits of the world would make you think America is the worst in every dimension and there are no downsides in other countries.
The more I read these conversations, it becomes clear that Americans don't actually want the healthcare systems and rules of other countries. They want most features of American healthcare, but without the pricetag.
There's a lot of room to work on improving how things get paid for, but I worry that anything that involves compromise or tradeoffs is DOA, politically. We want it all, we want it now, and we don't want to have to pay for it.
I needed a specialty ophthalmologist (for dry eye treatment) and the wait time in Seattle was 4 months. Another time, I needed a cardiologist appointment and the earliest one available within my insurance network's coverage was 5 months away. And I had literally the best insurance plan we could get.
Both appointments were at least several hundred dollars out-of-pocket.
I literally cannot see a specialist in the US without a referral or else insurance will deny it. And this is on a good healthcare plan.
> You then need to wait for something between 6-12 months (sometimes more, depending on your location) for an ophthalmologist appointment.
It took me around 2-3 months to see my doctor, and then talking to them it would take another few months to even talk with a sleep clinic.
> You wouldn’t need to pay for it out of pocket, but you’d wish you had an option to pay the damn 500 quid so that you can start the treatment sooner.
I cannot pay out of pocket to start treatment sooner because it would cost an insane amount of money and waste the large amount I pay on health insurance coverage.
You can also get referred from an optometrist, found in many high st opticians to a ophthalmologist. GPs are not very keen to deal with eye issues as they don't have the specialist training and equipment. Like the optometrist will likely have an OCT scanner but not your GP.
At a minimum there should be regulation (I know it’s a bad word now) to make the system easy to use without costly traps.
I like the style the Czech/German system is doing healthcare. It is public but kinda private. You pay to the government, but you decide where to go so the hospitals/doctors compete for your money. It is very different than the centrally planned Danish or English based where there's basically some person in top that decides everything.
The US is polarized with the republicans not wanting any socialized health care because they don't want to care for people not like them. You can't organize and correctly run a health care systems when half you politicians actively sabotage and burn it down.
Categorically, older individuals tend to vote more conservative and more republican. This doesn't make sense to me at all.
What makes more sense is that they argue against the socialization of any industry that funds their campaigns.
Democrats seem to take a more middle ground. ie Obamacare socialized low cost solutions and pushed costs uphill toward people who need more expensive care.
That's such an insane assumption to make.
I am forced to pay about 500 euro on mandatory public health insurance (tax) every month!
It's not even which facility, but which staff member! My mother had a pair of surgeries at the same facility, but the first anesthesiologist was in network and the second one was out of network. Both worked for the same place, but the second one was a contracted employee and so they bill differently then the direct hired ones.
It was a major mess and ended up costing us an extra 10k or so.
They literally just charged me the max they possibly could to my insurance. The insurance just said 'oh well' and paid part of it. Now I am in collections over 1/3rd of the amount I can easily pay.
The provider will not even tell me what procedures got it up to 4k. How the hell did that pass the insurance sniff test.
These jackasses are just sending out bills and hoping someone will pay it. Your credit screwed over. Oh well. They already got paid.
My mother ended up with a collapsed lung. The doctor caused. Then they charged her for it. My mom had a nurse hand my mom her own purse and my mom fished out a bottle Tylenol. 400 bucks.
No one knows what is going on or how things are being charged. At this point it is obviously on poupous. This is not health care. It is racket designed to steal money from people who are sick.
https://www.cms.gov/nosurprises/ending-surprise-medical-bill...
(Signed by Trump during the 2020 lame duck!)
If you look at it as a pump that’s intended to provide the worst possible care with the most friction it can tolerate and at the highest parasitic cost I’m certain you’ll find it makes perfect sense.
Logically and financially, a single payer system makes way more sense. No marketing costs, no CEO costs, no costs for the entire medical billing industry, no costs for excessive paperwork.
Just care.
When my mom was in hospice last year for a month before she passed, Medicare covered that 100%. It was amazing, it's like, didn't have to worry about being bankrupt after she passed. No paperwork for us to deal with, no surprise bills, etc. just care.
Imagine the world...
There are many problems with the US healthcare system, not the least of which is the fact that we have something like 18 different ones.
Yes, this is the same reason it takes 7 weeks and two referrals to have my car serviced, or my floors cleaned. Private industry is terrible at these things.
This is what regulatory capture does. It may be so-called "private" but the government still wants to regulate it up the wazoo, in all the wrong ways. This prevents new businesses from making things better.
> a single payer system makes way more sense.
If the single payer is the very same government then it becomes incentivized to bring the regulation in line to something more sensible. Of course, if the single payer is a separate entity that won't necessarily happen. For example: Amish communities in the US often administer a single payer system, but they haven't been able to fix the situation.
I don't think regulatory capture is an argument for getting the government out of this business, I think it's an argument for getting the business out of this business.
I get that they are maximizing profits. But why does the process have to be so clunky and complex? When I fly somewhere, I buy a ticket with the expectation of getting to my destination without much fuzz. My bags also usually get there without problem.
Translating the health care experience to flying, nobody could tell me how much the flight costs. After the flight I would get invoices from various baggage handlers which the airline would pay for or maybe not based on unknowable criteria. The copilot may be out of network so I would have to pay extra. The pilot may demand upfront payment. And so on.
My point is: Why can't this super expensive system not at least be a smooth experience? Like, you go to a doctor, they enter some data into a website and tell you how much it will cost. This shouldn't be hard to do.
The side of the transaction who has better visibility+analysis, the more likely they are to win on the transactions.
And yes.
Yes it is.
It's worse than that, there are also "tiers" within a network, even for different physicians under the same health group. We were actually debating moving our kids to a different doc (but in the same office!) because of this.
The whole system is madness.
Maybe the health care conglomerates in my city are decent but I’ve never ever tried to book any appointment and been told they are out of network. Never had a hospital experience where some random doctor was out of network but everyone else is.
https://www.nytimes.com/2022/06/30/well/live/surprise-medica...
> These bills arise because even if you visit an in-network provider, you can still be treated by an out-of-network physician who works there, said Karen Pollitz, the co-director of the Kaiser Family Foundation’s Program on Patient and Consumer Protections. “The doctors who work in hospitals generally don’t work for the hospitals,” she said. “They bill independently, and they can decide which networks they participate in.”
Things like a major operation where the hospital, surgeon, nurses etc. were in-network, but the anesthesiologist - who you may never have even encountered while conscious - was not.
https://www.nytimes.com/2014/09/21/us/drive-by-doctoring-sur...
> In Mr. Drier’s case, the primary surgeon, Dr. Nathaniel L. Tindel, had said he would accept a negotiated fee determined through Mr. Drier’s insurance company, which ended up being about $6,200. (Mr. Drier had to pay $3,000 of that to meet his deductible.) But the assistant, Dr. Harrison T. Mu, was out of network and sent the $117,000 bill.
> Patricia Kaufman’s bills after a recent back operation at a Long Island hospital were rife with such charges, said her husband, Alan, who spent days sorting them out. Two plastic surgeons billed more than $250,000 to sew up the incision, a task done by a resident during previous operations for Ms. Kaufman’s chronic neurological condition.
> “The idea of having an assistant in the O.R. has become an opportunity to make up for surgical fees that have been slashed,” said Dr. Abeel A. Mangi, a professor of cardiac surgery at Yale, who said the practice had become commonplace. “There’s now a whole cadre of people out there who do not have meaningful appointments as attending surgeons, so they do assistant work.” In Mr. Drier’s case, each surgeon billed for each step of the procedure. Dr. Tindel billed $74,000 for removing two disks and an additional $50,000 for placing the hardware that stabilized Mr. Drier’s spine. Dr. Mu billed $67,000 and $50,000 for those tasks. If the surgery had been for a Medicare patient, the assistant would have been permitted to bill only 16 percent of the primary surgeon’s fee. With current Medicare rates, that would have been about $800, less than 1 percent of what Dr. Mu was paid.
I just specify my insurance provider/plan in zocdoc and generates a list of doctors who are in network and their calendar of availability. I think this was a bigger hassle 10 years ago, yes.
That's only for the initial GP visits and maybe for simple tests. Once you get into specialized treatment, it's a whole another world.
For example, if you are admitted to an in-network hospital, an infectious disease specialist can be out-of-network, and you will have to pay for them.
The belief, and this is very apparent at the moment with all the stories about DOGE and the Trump admin, is that the government wastes money and the private sector can do it better. In cases where there's no return on investment to be had, Republicans would want that "free," government-provided service/product to be cut entirely (again, see recent DOGE actions). Btw, when I say ROI, in the eyes of Republicans, the more nebulous the ROI the more likely they are to say "kill it" because this really is about dollars and cents (with some culture war issues thrown in, but that's a very small part of the larger dollars and cents issue that almost all Republicans care about).
And to put a finer point on it, the Republican Party believes a significant percentage of the US population doesn't work hard enough (or at all) and that therefore those people don't deserve to get anything for free (i.e., I don't want to pay taxes or have the government issue debt for the sake of people who haven't earned it). That's why you'll have a hard time arguing that very wealthy people shouldn't take advantage of the government because in the eyes of Republicans those people have, literally, earned whatever they get, including "free" things from the government (this mostly takes the form of pro-business regulations/subsidies).
More specific to single-payer health care, if the US offered it, Republicans believe it would take away an incentive for people to work because for working-age people that's how you traditionally get health insurance. To repeat from above, no work = nothing free. That is a feature of the system in the eyes of Republicans, not a bug.
For those wanting to understand more, ask ChatGPT/Google/etc. for Republican proposals for how to manage Social Security, Health Care in general, Medicare specifically (see "Medicare Advantage"), Medicaid, food stamps, Social Security Disability, etc.). If you really want to understand it fully read it straight from the Republicans' own websites. Visit the Heritage Foundation, or Americans for Tax Reform). Every one of these topics is discussed in detail. Particularly relevant at the moment given this administration is doing much more to make all of this a reality. Prior Republican admins did some of it as well, of course, but not as aggressively as this one.
I say this on a lot of my (mostly long-winded posts--sorry!): I'm attempting to be factual here. If you're reading a politically-biased angle please reply and say so, and if you can tell me which words in particular are triggering you, I'd genuinely like to know because my intent is to communicate the rough facts on the ground.
edit: changed one incorrect word
A private health system can work. There's nothing inherently bad about it. A private system with some subsidies for poor people can work fine.
The problem is that in our health system, the incentives are misaligned. There is no market for insurance policies outside the ACA, most people have no power to choose their insurance provider.
One easy fix is to prohibit employer-sponsored insurance entirely. At most, allow employers to provide vouchers that can be used only for healthcare purchase.
To give my personal opinion, if given only choices on the poles (fully private vs single-payer), I’d vote for single-payer. And I’d actually do it because I think the ROI would be enormous, though difficult to quantify. I do think it’s tricky (at best) to have health care fully private because the profit motivation can be cut throat. Maybe you’re right though it could be private but with heavy regulation (sort of sounds like what we have today though for working-age people). And you didn’t say regulate it but I’d have a hard time agreeing private could work without regulation.
The same drug is now available in the form of a self-administered pen which is far less expensive and more convienient. However, that falls under the purview of CVS Caremark, who Anthem has designated as its pharmacy benefits manager. CVS Caremark is denying the pen, saying I have to try a whole host of other meds which do not work for me first.
I talked to Anthem yesterday, and they have no idea how to get this approved. Their best suggestion is that my doctor schedule a call with the CVS doctor to argue with them. My doctor is not motivated to do this, as I'm already getting a treatment that works for me.
So I'm stuck wasting hours every few weeks for an infusion that could be replaced by an injection I give myself. And the hilarious part is that the insurance company stands to benefit the most, as they would pay far less.
This is the kind of thing that, if we had actual socialized medicine, I might be able to appeal to a government official to fix. But how can you appeal corporate bureaucracy?
- the name, license #, and board-specialty of the physician making this determination
- copies of all materials used to make this determination
- proof the doctor making this determination has maintained registration in your specific state and documents proving they meet all their continuing education requirements
- the aggregate rate at which this specific condition is denied or approved by this specific doctor making your determination
(YMMV, I haven’t had the opportunity to try this, though it comes highly recommended from a physician’s assistant who deals with this bullshit endlessly)
However, this may change. See [1], p. 465, which proposes to make "Medicare Advantage" the default.
"Medicare Advantage (MA), a system of competing private health plans, is the major alternative to traditional Medicare for America’s large and growing cohort of seniors. The program provides beneficiaries with a wide range of competitive health plan choices—a richer set of benefits than traditional Medicare provides and at a reasonable cost. Equally as important, the MA program has been registering consistently high marks for superior performance in delivering high-quality care. Critical reforms are still needed to strengthen and improve the program for the future. Specifically: 1. Make Medicare Advantage the default enrollment option. ... "
[1] https://static.project2025.org/2025_MandateForLeadership_CHA...
If you can afford a good Medicare supplement (type F if you can get it), and can cover eyeglasses and hearing aids yourself, that's the most comprehensive coverage. But it will cost more.
[1] https://www.kiplinger.com/retirement/medicare/medicare-advan...
Plan F is not open to new enrollees in less they were eligible for Medicare before 2000-01-01 and so the pool of people with plan F is shrinking and aging.
Plan G on the other hand is open to all, and is the most popular choice for new Medicare enrollees with something like 70% of the people who buy a supplement plan choosing it. That gives it a younger and growing pool.
Accordingly plan G is generally cheaper than plan F which is usually more than enough to make up for not covering the $257 deductible. G just needs to be at least $21.42 month cheaper than F to come out ahead which is the case in a few sates I looked at.
Health Insurers Deny 850M Claims a Year. The Few Who Appeal Often Win
https://news.ycombinator.com/item?id=43032224
UnitedHealth Is Sick of Everyone Complaining About Its Claim Denials
Don't do it.
could you please explain in more detail why a move to medicare advantage from regular medicare is a bad decision?
i'm asking because a family member is on regular medicare but is being pressured to move to an advantage plan. i would like some facts to help bolster his decision to stay on regular medicare (since i've also heard MA is a bad idea). thanks in advance.
could you please explain further? why is MA worse than regular medicare? a family member is being pressured to move from regular medicare to advantage, and i need some facts to help them see why advantage plans are worse than regular medicare. thank you.
What else would it be to them? They're not a charity. I don't see why people keep directing their hate toward the corporations for doing what they're intended to do. The hate and effort should be directed toward the politicians who prevent the implementation of changes that people want. Or do the majority of people not want changes that would prevent this kind of thing?
I mean, they could be a not-for-profit entity.
> The hate and effort should be directed toward the politicians who prevent the implementation of changes that people want.
Why not both? I can be mad at the companies who are purchasing those politicians, too.
> The hate and effort should be directed toward the politicians who prevent the implementation of changes that people want.
Who do you think is hiring the lobbyists to pay off the politicians?
Who do you think is paying the media to make sure people don't know that we're actually pretty agreed on this issue?
I have enough anger for 'both' political parties, the corporations that buy them, and the media (social and corporate) that runs cover for both. And I'm not remotely apologetic for that; I believe it's the only rational and humane opinion to have about healthcare in the US.
Again, it's not the hiring of the lobbyists that should be surprising, or where the effort and anger should be directed in my opinion. It should be toward the politicians that actually accept those payoffs. Of course an entity incentivized to maximize profit is going to lobby to improve its position. The elected representatives should behave in such a way that those lobbying efforts are wasted. Also the system should be organized so that it can't happen in the first place.
That being said, it's not like Kamala was going to go after making healthcare any cheaper. It's a duopoly that is funded by corporations no matter who we chose.
Bernie had some chance but the duopoly didn't like him.