How often have we heard someone — who has decided to forego health care coverage — say, “It’s not going to happen to me”?
Then the worst health care “event” does happen.
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Maybe it’s an unexpected heart attack that requires a four-vein bypass, a week in the intensive care unit, another six weeks out of work — and a $250,000 hospital bill. That doesn’t count the bills from all the medical specialists who were necessary along the way — or the rehab program.
This experience is not isolated. It could come at any time and to any of the 20 million people who are still without health care insurance protection in this country.
The goal of the Affordable Care Act was to provide an opportunity for coverage for the 40 million mothers, fathers, sons and daughters who could end up facing a debt they could never hope to repay — or face bankruptcy. While the number of uninsured has fallen by about half (for a variety of reasons), the results of the recent presidential election have once again opened up debate on the ACA for either repeal or significant changes, since the promised rate reduction and the ability to remain with the physician of one’s choice never came true.
One area that doesn’t get much attention is the unconscionable fees for many health care services.
One area that doesn’t get much attention in the health care debate is the unconscionable charges rendered for many health care services. In a real-life example, a middle-aged female underwent an ablation procedure for atrial fibrillation in a local cardiac facility. Upon discharge, her bill from the facility was $96,000. Fortunately, Medicare and a supplement policy settled the claim for $18,000.
This practice of submitting exorbitant claims goes back to Medicare’s mandate for itemized billing that includes the charge and description of each surgical procedure, medical service and supply furnished.
Hospitals took Medicare’s stipulations to heart. For example, patients were charged $5 for an aspirin tablet or a 4X4 gauze pad — and the charges went up from there. The treatment facilities knew they weren’t going to be reimbursed even close to the billed amount, but the feeling was the more individual charges were loaded onto the bill, the more they hoped to be reimbursed.
The payers, including Medicare, are now wrestling with itemized billing by pushing for “bundling” charges — a method the payers of health care services can arrange with the institutions to arrive at more appropriate reimbursement determinations.
What are not included in either the itemized billing or the “bundling” arrangements are the patients who have inadequate or no health care protection. These patients are personally responsible for the costs they incur. They are the patients who face bankruptcy or a life of debt if they or a family member struggle through a severe illness or injury.
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The debate in Congress will be over penalties, employer and individual mandates, high-risk pools, preexisting conditions, interstate coverage offerings, tax credits, vouchers, portability, medical savings accounts — and creating an affordable basic benefits package.
Where is the discussion about mandatory universal catastrophic health care coverage?
Catastrophic coverage was one of the main reasons that Medicare and Medicaid were both enacted — to protect the elderly and the underprivileged from financial ruin.
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In all likelihood, there would have to be an additional federal program or policy by a private consortium that could provide this type of coverage: very high deductible, coupled with very high limits, similar to cancer policies. The only way to make the additional costs affordable would be to spread the risks and costs throughout the population that would potentially need it — and that is those who choose to not obtain coverage through any existing programs.
Unless all patients have some type of health care coverage protection for their catastrophic maladies, countless Americans will continue to face a lifetime of debt or bankruptcy. In either outcome, the unpaid debt falls on the shoulders of the health care institutions and/or the taxpayers — to make up for the shortfall.
Rob Tenery, M.D., is a Dallas-based ophthalmologist and writer, and the third of three generations of physicians.