Hello, and welcome to another episode of Nutrition is the Key to Health.
As with most of my episodes, I want to start off by asking you a question. Do you think you have good health insurance coverage, or do you even know? Health insurance is critical when a tragedy or illness strikes you, or someone in your family.
Some individuals do not know their coverage amounts. They rarely have to go to the doctor and they have one or two scripts that are covered by their insurance. So, they think it is great. That is until they experience an accident or major health event that sends them to the ER and possibly buys them a stay for several days in an inpatient facility.
Most people are confused by the EOBs of Explanation of Benefits that is sent each month. You start losing track of everything and this can cost you money. The insurance companies are counting on it.
Currently, most health insurance is what I call “crisis” insurance. It only has a stop-gap after you reach your out-of-pocket maximum. Let’s say that a family of three is involved in a car accident. They thought they had good health insurance through their coverage, but come to find out, their deductibles might be separate for each individual, as well as their out-of-pocket maximums.
This means that depending on their out-of-pocket maximum, they will be on the hook for 6-9000 dollars for each member of the family that goes to the ER. That one trip could cost the family 18-27K or more. This day and time it is enough to put anyone if a financial stronghold. Healthcare bills are the number one reason people have to file bankruptcy in the US.
It is estimated that roughly 28M people in the US are uninsured. Also, more people lost their jobs this year to layoffs and terminations and they cannot afford COBRA, and had to reach out to the Affordable Care Act or ACA plans for coverage. It is said that 2024 has been a stellar year for ACA coverage and I believe it is for this very reason.
Disclaimer, I am not a physician, nurse, registered dietician, physical therapist, or mental health professional. This is my story and what I have done and learned over the course of my journey. If you plan to start a diet or exercise program, please get approval from your doctor.
Health insurance can be very confusing. Now, I am not an expert, nor do I sell health insurance, but as a lifelong patient, I have learned some very valuable lessons the hard way, along the way.
So, I advise you to dig into yours before you have a health crisis or event.
There are many types of insurance, but we will look at these main types:
Group Policies – these are negotiated and offered by the company you might work for.
Private Polices – are just that, they are underwritten for each individual according to their level of health. Only healthy people will qualify for these policies. If you have heart disease, cancer, mental illness, or any other condition, you will most likely not even qualify.
ACA Policies– or Affordable Care Act
This is an option for those who have lost their job or their companies do not offer health benefits and the rate at which you will pay, and will depend on your income. Currently, pre-existing conditions are covered, but that is always subject to change depending on who is in the White House.
Medicare – A federal health insurance program in the US for older people and people with certain disabilities.
Medicaid - is a health program for certain people and families with low incomes and resources.
CHIP- The Children’s Health Insurance Program which is administered by the US Department of Health and Human Services that provides matching funds to states for health insurance to families with children.
Now under group policies, there are subtypes. You can have a choice of HMOs, Choice PPO or High Deductible Health Plans. Each company is different in their offerings.
Each one has pros and cons, depending on your state of health. The more coverage you need, the more money you will pay each month in premiums.
Back in the early 1990s, when HMOs were prevalent, we could pay one small deductible and choose any provider we wanted. The premium cost was roughly $50 a paycheck. Once you paid your deductible (which was usually 500 dollars), the plan would absorb all other costs. We complained about all the rules of this policy, like having to get referrals for every specialist, but we all wish we had it back. Gone are those days. HMOs are making a comeback but with different rules, and these rules benefit the insurance companies and corporations and they are very restrictive.
Now, we have policies with extremely high deductibles, coinsurance, and copays. We are now burdened by taking on a greater portion of the premiums each month.
Let’s get into some basics of health insurance. Health insurance is more important than ever before. I don’t think anyone, whether it be a Republican or Democrat, in this country will not agree that our system is broken, and needs a complete rebuild.
However, our bi-partisan friends in Washington, cannot seem to agree on any reform to our healthcare that will help the people of the United States, so the Insurance agencies, and pharmaceutical companies, keep posting record profits in the billions each year. Meanwhile, the insurance companies get to regulate who lives and who dies (sort of). More on that later.
According to the Center for Responsive Politics, from the Senate Office of Public Records, the two top lobbyist groups in the United States are the following:
1. Pharmaceutical and Health Products Lobby spend over 4.4 billion dollars/year
2. Insurance (Health, Property and Auto) Lobby spend 3 billion dollars/year
First, companies as big as these, do not spend that kind of money each year, unless they are getting an ROI or return on investment. So, these companies have the ears of our government and they are using their political muscle, in the form of their money and political contributions to potentially influence our politicians to vote, or take certain actions, to benefit them.
When in office, Trump, tried to repeal the “pre-existing conditions” protection clause, for all Americans who have any documented health issues. Why is this such a big deal? Well, let’s think back to some of the stats.
· Almost 16M of all Americans have heart disease according to the (American Heart Associate)
· 1.9M have cancer (2021) American Cancer Association
· Almost 50% of American Adults have high blood pressure or hypertension, with another 1 in 25 children having the disease.
· 37M Americans have Diabetes
· 800,000 Americans have strokes each year
· 27 M Americans have/have had Covid
· One to two percent have Autism
· 1 in 15 have been diagnosed with Autoimmune Diseases
· One in five Americans suffer from mental illness
· 30 M Americans have an eating disorder
· 6 M have Alzheimer’s with another 2 M with dementia.
· 11% of Americans have a seizure disorder.
· 5% of children and 2% of Adults have ADHD
That means that if you have ever been diagnosed with any disease or disorder, you would get a rubber stamp of having a “pre-existing condition”, and the insurance will not cover it. It hardly seems fair, does it?
In other words, your insurance company would not have to pay a single penny toward any future issues you might encounter even though they might be life-threatening. Individuals with pre-existing conditions are not insurable on the private markets, so we are left with group or government plans.
What does this mean for people like you and me if the pre-existing clause is repealed? We would never get coverage again. So, each time we would go to the doctor or hospital, we would have to pay 100% of the bill and no pharmaceuticals would be covered. Could you imagine being a diabetic, heart, cancer, or seizure disorder patient, and having to pay for your meds each month? Those drugs can run $2000 a month for one script. How about it if you have a heart condition and need a life-saving procedure? Same scenario.
Also, if you have a child that has leukemia, autism, or ADHD, the same will apply. The insurance carriers can charge you an astronomical rate to cover or deny coverage altogether. Maybe you have high blood pressure, or had a heart attack at 40 years of age, that too, would be “pre-existing”. These would hold for any other disease such as cancer, heart, diabetes, stroke, psychological issues, and even issues with childbirth.
All would be “pre-existing” and not covered! Maybe you are in your twenties or thirties, and perfectly healthy. If that is the case, then I applaud you. So, your attitude might be, “So, what, this doesn’t affect me”, and you brush it off without a care. I will tell you that it will affect someone in your life if not you, so you need to think long and hard about that way of thinking.
According to Benefits.com, the top healthcare company revenues soared to almost 1 trillion dollars! So, all your companies, made an enormous amount of profits in 2019, to the tune of billions.
A repeal of the “pre-existing” clause, would send the people of the United States to bankruptcy court and ruin the lives of many families, and put more money in the pockets of these insurance companies. That is why the two highest lobbyist groups, and donations to political campaigns, are spending billions each year in Washington D.C.! They are buying favorable legislation to ensure their profits remain high at any cost, your cost!
Let’s get into some of the terminology
Premium
This will be your monthly or bimonthly payment that you will make. Most premiums on a group plan will be shared, meaning the employer and the employee will share a certain percentage of the cost. It depends on your employer as to the shared amount the employee will pay. I can tell you that the employers are continuing to burden the employee with more of the premium cost each year. They are also decreasing the level of benefits the employee receives.
Coinsurance
A form of medical cost sharing in a health insurance plan that requires an insured person to pay a stated percentage of medical expenses after the deductible amount, if any, was paid. This would be a typical 70/30 or 80/20 policy.
Copayment
A form of medical cost sharing in a health insurance plan that requires an insured person to pay a fixed dollar amount when a medical service is received. Depending on if you have met your deductible for the year, depends on if you or the insurance will pay.
Deductible
A fixed dollar amount during the benefit period that an insured person pays before the insurer starts to make payments for covered medical services. Plans may have both per individual and family deductibles.
Insurance companies wheeled more power than ever when it comes to your treatment and what they will allow. The are strictly profit over patient. They decide who gets what surgery, when scans will be approved, and get to say no to individuals that need to take certain drugs. They even get to decide if a breast cancer patient gets a mastectomy vs lumpectomy. It doesn’t seem right, but this is our healthcare today. The government continues to allow them to dictate full courses of health treatments without any repercussions.
I urge each of you to look at your benefits. The rules of your coverage will be laid out in the SPD or Summary Plan Description. This is where you will find all the fine print and legal ease. Something that you assumed was covered, isn’t, and it is all spelled out in the Summary Plan Description.
Some employers like to play cat and mouse with this document. Like my last employer. I asked HR for a copy of the SPD and they said I would have to contact my healthcare provider. I called the healthcare provider of the policy and they said they do not have access to this document and I would have to contact HR. I never got a copy. I knew it was the responsibility for the HR department. I was trying to determine if my critical illness policy would cover an event should I have a stroke, heart attack or reoccurrence of cancer.
I found the policy buried deep inside the employee portal. When I read the requirements, I found that I was paying a lot of money each month and the insurance would not even cover a reoccurrence of cancer, unless it was a different type. It did not cover pre-existing conditions.
So it pays to do your research and get informed, or like vitamin supplementation, you are just wasting money.
Also, make sure that if you go to the hospital that you do not have to get a pre-authorization. If you do go to the ER and you didn’t get one, they will determine it was not an emergency and deny all coverage, so you will be on the hook for 100% of the bill. Also, if you leave AMA, or Against Medical Advice, they will also deny the claim. So, think twice about walking out.
I hope this gives you some basic information and has encouraged you to check out your policy and any restrictions. The insurance companies are not issuing policies to lose money. It is an insane profit for them.
See you next week,