Entrepreneur: The Face of the Uninsured Looks Like Me

I’ve sat listening to the ridiculous debate on TV about the recent Supreme Court decision to uphold the Affordable Care Act – I can’t help thinking that these people don’t get it. They just don’t understand who the uninsured is or what the uninsured in America face. It’s quite easy for people who have “good” insurance to decry the rest of us and find ways to say let’s repeal “Obama Care” – when you repeal it what are you putting in its place? When you can answer that question and offer me coverage that I can afford that doesn’t have pre-existing condition exclusions, I will be willing to listen to your alternative, until then shut up and here me out.

At this point you may have stopped reading, but if you haven’t let me tell you my story, hopefully the next time one of these talking heads comes on TV with a mindless “Repeal” nonsense you will be more educated and hit the remote control. Having health insurance is a human right – it is my right to access good medical treatment that will keep me alive so I can continue to be a productive American Citizen – this is not negotiable nor should we be willing to compromise our own self-interest for political nonsense. The politicians who want to repeal the only chance most of us have to be insured – have health insurance. They have access to the “Best Care” paid for by your tax payer dollars – guess what you don’t. If your employer lays you off, outsources your job to China or any other country – you join me and millions of others who are uninsured. Having money doesn’t guarantee you coverage as my story will illustrate. There are thousands of people out there who would love to tell corporate America to kiss off but they are too scared to do so because dear God, that would mean they don’t have any insurance coverage. So we have managed to stifle growth as we have this ludicrous debate about is it a tax or is it a fine. Those of us who are uninsured will gladly scrape together whatever money we have and pay the premiums you impose just to have the security of knowing that God forbid something serious happens we have an insurance card we can drop in the hands of the doctors’ office. There are very few people who will not buy insurance after being uninsured for decades – so let’s dispel that myth immediately.

Yes, I am the face of the uninsured or under insured in America. I own my own business, I make a legitimate living, I work super hard but I have two simple pre-existing conditions that prevent me from getting insurance. In fact, I have been declined by most of the big 4 insurance companies and there is no hope of getting coverage unless I declare that everything that is wrong with me went away overnight. I would then have to erase my medical records, get a new identity or move to a State that has no history of my past under an assumed name. But I am not willing to do that. So in essence I don’t meet the underwriting criteria to be offered insurance coverage at a rate that I can afford or coverage that will pay a dime for the stuff that is now wrong with me.

How did I get here? Simple story, I became a business owner. By that simple decision I became uninsured. After leaving my corporate job to start my company, I continued my health insurance via Cobra until they cut me off. I did Cobra Individual Conversion Continuation that ended after 18 months, I then did an Individual Plan until that too ran out because the insurance carrier decided to discontinue the program for underwriting reasons. I creatively stretched my former employers’ coverage for over 4 years after I left Corporate America by paying for the coverage out of pocket.

But in 2002, I became uninsured. My luck ran out and I had nothing. After I became uninsured my family doctor worked out a payment plan “The Uninsured Cash Plan” I could pay $55 to see her for my routine stuff. She would bill my lab work under her global account which had some discounts and I would pay her office the charges for my lab work each quarter. She even had a list of places I could get X-Rays for discounted prices – I utilized the annual mammogram discounts offered during October so at least I could have basic care. I did this Band-Aid of a health plan for 3 years praying every day that I wouldn’t get sick enough to require hospitalization. Then one afternoon I had a pain under my right arm. Please note I said pain – I didn’t say that I had anything major wrong, I simply had pain. My doctor said watch it and if it doesn’t go away soon I will order a mammogram with an ultrasound of your under arm. Again I prayed, because prayer became my health insurance plan. Eventually the pain went away, but really I willed it away and I went about my business.

In 2005, business was good so I started hiring staff. After my fourth hire in 2006 I decided that I would get better candidates if I offered health insurance. So I enlisted the help of a broker and mustered enough courage to go out for a quote. We were instantly insurable because my entire staff was under age 30. This wasn’t deliberate, I had a budding internship program and we hired most of our interns. So once again I joined the ranks of the insured. This happiness didn’t last long. I visited my primary doctor who happened to be the same person who provided the “Cash Band-Aid Coverage” for 2 years. She was quite thrilled that I had insurance and she did a complete physical and ordered my annual mammogram. As she thumbed through my chart she noted that I had the underarm pain which I mentioned on and off for 2 years, so she ordered an ultrasound of my under arm as a precaution. She put underarm pain as the rational for the ultrasound and then she added hypertension as the cause of my visit. I left her office and proceeded to schedule my mammogram and ultrasound knowing good and well that it would be covered because I paid the premiums. I was insured for crying out loud – I didn’t feel like a second class citizen when I arrived at the doctors’ office without an health insurance card.

The premiums for my coverage and the coverage of my staff members, was to the tune of almost $4500 each month – my share of the coverage was $750 because I was rated higher because of my age and the fact that I was a woman who was still considered of child bearing age – legal price gouging based on gender. (I had no intent to have any more babies – but I was paying for the fact that I could possibly have one). To cover my husband and then 14 year old son was a whopping $1400 – the family benefit premium. I was ok paying this money because I could now sleep at night because I had “coverage.” The coverage came with a $2500 deductible, co-insurance of $250 day for in-hospital stay and a $65 office visit copayment for primary doctors’ visits and a whopping $85 copay for specialist. As you may recall, I had a working payment relationship with my doctor a $55 arrangement that was now $10 more on top of an exorbitantly high premium.

A few weeks after I visited my primary doctor, had the mammogram and ultrasound I got an Explanation of Benefits from my insurance carrier. They informed me that they would pay for my mammogram because that was covered by law but they wouldn’t pay for my office visit, my high blood pressure medication nor would they pay for my ultrasound. (The ultrasound was negative – and I only needed a refill of my blood pressure medication) They were all denied for pre-existing conditions – the pre-existing condition “pain” and high blood pressure. They further advised me that we were underwritten post binding and nothing that occurred in the two years prior to the inception of the policy would be covered. They actually requested medical records from my primary doctor and all the subsequent doctors I saw in the 5 years before they offered me coverage. To make matters worse, then promptly sent me a list of things they wouldn’t cover – it was almost everything I had ever had in my entire life. Keep in mind when we applied for coverage I filled out a medical questionnaire and I listed all of this crap – clearly so they could see what they were getting into before they offered me coverage, the premium was based on the medical history we provided. So basically, my hypertension, blood pressure medication, pain under the arm would be denied for two years and all related cardiac conditions that could arise out of the hypertension would also be denied. They would also deny any of my female related issues because they too manifested themselves before the start of the coverage. So the health plan would collect my premiums and deny payment for anything that was wrong with me or my family. The same disingenuous message was sent to my employees when they attempted to utilize the insurance coverage; they denied everything from acne to hang nails. We were considered a small group subject to underwriting guidelines – because the pool was too small and we were too risky.

The Radiology Center that did my ultrasound promptly billed me for the full cost of the procedure $395 – even though the insurance company only approved $58 for the procedure. They told me in no uncertain terms that they would send me to collections and they informed me that they had no contract with me, furthermore they would not accept the $58 approved amount because the charges were denied. Had they been applied to a deductible they would have accepted the $58 but since it was flat out denied I was on my own. My account was shifted to self-pay, meaning uninsured – but hell I had coverage, I paid my premiums how could this happen to me? So to protect my credit I paid the $395 promptly in the same week I cut a check to the insurance carrier for my company’s premiums.

So in essence, I was obligated to pay the carrier and I would get nothing covered for two years unless I had a cold that manifested itself immediately after the coverage inception and don’t let there be any trace of chronic colds in my past medical history (which the insurance company had on file in their office to peruse every time we submitted a claim for payment) – because that wouldn’t be covered either. Because I have no good sense and because I had promised my employees health insurance I continued this nonsense for over 2 years. In 2008, when the economy tanked and I laid off most of my staff I once again suffered the faith of being uninsured. At my renewal in 2009, the insurance carrier notified my agent that because my employee census fell below their guidelines we weren’t eligible for renewal. So in essence they kicked us off after collecting $108,000 in premiums during the period I had employees and $24,000 when I was down to two employees. We checked and they didn’t pay even 1/100 of a percent of the premiums collected out in claims. Remember, I had a young healthy staff – I was the sicko and they weren’t paying my bills!

So once again I joined the ranks of the uninsured, the kicker of this story – I built the first half of my career working in the insurance industry – the same industry that kicked me to the curb. I am a savvy consumer, I know how to navigate the system but guess what the system was built around collecting not paying. No one cares about your well-being when you don’t have that all infamous “insurance card” – so to all the “Repeal” folks, if you can give me an option that offers me insurance, good coverage and the ability to overlook my medical issues I will gladly sign up. Until then shut up and keep the process moving as I hold my breath until 2014 when I can access affordable care that isn’t based on my pre-existing conditions. Given the fact that I am older, I’m sure there’s more stuff wrong with me I couldn’t get a fly by night insurance company willing to offer me coverage much less one of the big 4. In addition, I have gone years uninsured which means I now don’t meet any criteria except sick – so there are no options for me. I don’t qualify for Medicaid – because I work, I’m too young for Medicare and I can’t find any other option – so tell me what do I do when I’m sick? My husband was diagnosed with Cancer in April – thank god that occurred after he was eligible for Medicare, if not I would have to mortgage our home to pay the $80,000+ for is Cancer Treatment. Even with Medicare the Oncologist sent us a bill last week for $6900 that is the first round of copayments for his Radiation treatment. I can’t afford to be sick even for one second because as an uninsured person my bill would be $80,000 not $6900!

The Affordable Care Act health coverage process may not be the best option – frankly the Democrats blew it by not having a public option, but I will settle for this option becasue frankly we have no choise. We are the only industrialized nation that makes health care a business. People and corporations get filthy rich off of your being sick.  So, the cycle for the uninsured and sick – use the Emergency Room  as your primary care physicians office. When you can’t pay the ER bill – the hospitals and medical providers line up to sue the crap out of you – the alternative just go off in a corner and die while some Senator tells you that we have the best health care in the world. He can say that becasue he has health insurance bought and paid from your sweat equity.

Is this the system we (you) want? Are we so entrenched in our politics that we are willing to act against our own self-interest while totally rich people who have excellent insurance coverage that is paid for by our tax dollars control our destiny? Try being sick with that insurance card in your pocket and you will quickly find out what’s covered and what’s excluded – and you will find out just how much is cost to be sick in America.

Let’s ask anyone who thinks the Affordable Care Act is a mistake to give up their insurance card for 1 year – walk in my shoes then tell me the system is perfect and it doesn’t need to be fixed now.

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Margaret Spence

Margaret Spence - CEO of C. Douglas & Associates, Inc., Keynote Speaker on Diversity, Women in Leadership, Mentorship and Workers' Compensation. Business strategist & consultant to Fortune 500 Corporations. Founder of "The Employee to CEO Project"


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