Medical Necessity: Here we go again

If you want to understand why your rates keep going up, you can lay a big chunk of the blame on items like this (in email from Medical Mutual this morning):

"To be compliant with the non-discrimination rule outlined in the Affordable Care Act (section 1557), we will remove broad exclusions for gender transition treatment"

Let's dial back a bit, and talk about why this is so stupid. In the earliest days of this blog, we participated in a discussion with other bloggers about medical necessity and In Vitro Fertilization (IVF). We averred that:

"[A]ccording to the standard industry definition, “medical necessity refers to treatment which is required to treat or care for symptoms of an illness or injury or to diagnose an illness or condition that is harmful to life or health.” Thus, we see that IVF fails to meet the threshold of “medical necessity,” ergo it should not be covered by insurance."

That is, no one has ever died because they couldn't/didn't get pregnant. Likewise, there is no evidence that anyone has ever died because they didn't get their personal bits chopped and/or replaced (excluding obviously medical issues like cervical or breast cancer and the like). There is, however, ample evidence that these folks are at much higher risk for attempting suicide (which would then require medical treatment in the most expensive part of the hospital).

So when insurers are forced to pay for non-medically necessary procedures, that cost is going to be passed along in the form of higher insurance premiums. Now, am I blaming Medical Mutual for this change? Of course not, they're simply following directives sent down from Our Betters in DC©.

What choice do they (or any other carrier) have?

It's not rocket surgery, after all.

More 3000% rate decreases

This never gets old:



So two more individual medical renewals hit my desk this morning. Both are with the same carrier, both are HSA-compliant with $3000 per person deductibles then 100%, both are grandmothered (meaning they're only partially ObamaCare-compliant, but still "kosher") [ed: for now]:

Sally and her family of four currently pay about $930 a month; their rates are going up 15%, to $1,065 per month. This means that the family will spend just shy of $13,000 before the plan pays bupkes.

Still, that's a bargain: a comparable fully compliant plan will set them back about $1200 a month, and that's with a $6500 per person deductible. So they'd have the privilege of more than doubling their medical expense out-of-pocket while paying only 20% more in premiums.

Such a deal!

Terry's increase is 17%, from $295 a month to about $350. That's also still a bargain: a comparable new plan goes for $480 a month and also comes with a $6500 deductible. This means that Terry would be out almost $11,000 before the plan paid a dime. Well, except for pap smears, mammograms and birth control convenience items. Oh, did I mention that Terry's a 53 year old guy?

And they're the lucky ones.

Insurance working properly, Wellmark-style

They say that "the exception proves the rule," and I think that FoIB Allison Bell has found the exemplar:

"Wellmark Blue Cross Blue Shield of Iowa says it spent $18 million on medical bills for just one patient in 2015."

And that's just from July forward. The patient suffers from a ""severe genetic disorder," and is racking up about $1 million a month in claims. In fact, this one insured accounts for some 10% of the almost 43% rate hike Wellmark's seeking for 2017. As this is a fully compliant ObamaPlan, there's no end in sight, since there's no cap (aka "lifetime maximum").

So why do I call this "insurance working properly?"

Well, because insurance should be about spreading the risk (and the pain). And this certainly qualifies: no average person could afford this kind of health care spending on his own. And since it's a genetic disorder, I don't feel any moral qualms as I would for someone with a lifestyle-related condition. This is simply the hand that this person was dealt.

And yes, it's a lot of money, and money means resources, being spent on one person. My faith requires me to "choose life," and that's the over-arching sentiment here. It's not for birth control convenience items or routine expenses, it's for a catastrophic claim, what health insurance should be about.

May this poor soul find a path to healing.

Mid-Week Linkage Roundup

■ From the "Everything Old is New Again" Department: My late mother had Post-Polio Syndrome, a result of childhood exposure, but (thankfully) she never had the full-blown version of the dread disease. A common treatment for those that did was the so-called "iron-lung." Fortunately, we've long since eradicated polio, but FoIB Allison Bell warns that we may have to dig those old machines out of mothballs:

"Zika May Be Polio All Over Again ... the CDC concluded, “after careful review of existing evidence,” that “Zika virus is a cause of microcephaly and other severe fetal brain defects” in newborn infants."

Heads' up.

■ Co-Blogger Mike thinks that Belgium might be catching up to Sweden in the Bizzaro World medical tourism race:

"Euthanasia tourists are flocking to Brussels to get a lethal dose. Doctors at hospitals and clinics at Belgium’s capital are seeing an increase in number of euthanasia tourists who are travelling from across the world"

Supply and demand.

■ FoIB Jeff M first alerted us to troubles brewing for North Carolina's Blue Cross franchise back in May. Today he shares this update in the continuing saga:

"The N.C. Department of Insurance announced Monday it will broaden its investigation into Blue Cross and Blue Shield of North Carolina, citing “disagreements” with the insurer."

At issue are continuing IT and claims processing issues.

Gotta love the tech.

■ And finally, via FoIB Holly R, this sad (and highly unusual) case from Great Britain (and for once, it's not about the MVNHS©):

"[A] 61-year-old British bagpipe player who developed a dry cough and breathlessness that worsened over a period of seven years ... He died several weeks after entering the hospital"

Turns out, several different - and deadly - fungi had taken up residence in his bagpipe, which he had neglected to clean. Truly sad, but perhaps a helpful warning to fellow pipers.

Death by Amazing Grace?

Tick-Tock: Welcome to the Walmart Marketplace

As we noted earlier this month, agents have the opportunity to sell ObamaPlans at Walmart stores around the country. But the window for signing up to do so is closing.

From email:

"Tomorrow (August 31) is the last opportunity for agents and brokers to sign up to enroll consumers in Marketplace plans in Walmart stores.

In order to participate in this Walmart event, you must hold a valid state license and be trained and registered to participate in the Marketplace for 2017."

Interested? Then click here to get started. And any readers that do choose to participate are encouraged to let us know what you think of the experience.

MVNHS© circling the drain?

Earlier this month, we noted the financial difficulties facing the Much Vaunted National Health Service©, and observed that if you're a government-run health care system and you're going broke, that's a problem. But it's not the only problem - lack of self-awareness is also strong:

"Yet oddly, rationing is not entirely dead. It is alive and well and making a comeback in our “precious” National Health Service." [emphasis added]

Just now noticing that, Jeremy? Had you been a regular IB reader, you'd have seen examples for years. Better late than never, one supposes. And he does, in fact, make an extraordinarily brilliant point:

"In a tax-funded health care system, the normal, self-limiting rules of supply and demand don’t apply."

Which is exactly right, and we're already seeing signs of it here, with only a partially government run health care scheme:

"A majority of new enrollees are considered high risk, meaning insurers will have to spend more money on people in poor health and requiring expensive  care."

Mr Warner goes on to point out three "new elements" that have entered the picture: mass communication, an aging society, and ever-growing, ever-changing tech. Notice the elephant in the room that he doesn't mention?

[Hat Tip: FoIB Peter K]

History Can Be Fun

Shortly after ACA was enacted into law in 2010, Senate Finance Chairman Max Baucus, whose Committee wrote most of it, "tried to calm an angry Montana voter by saying this: “Mark my words, several years from now, you’re going to look back and say, “Well that wasn't so bad after all”. 

Senator, we did mark your words.
 
It’s now been several years. 

It's pretty clear the average person today would NOT say: “Well, that wasn’t so bad after all”.  

In fact, a great many Americans are still looking for a good reason to calm down about Obamacare.

I think perspectives like these help explain why history can be fun.

Now in fairness to Senator Baucus, he had begun to change his opinion of Obamacare, in fact had become a critic, within a couple years of its passage.  Not necessarily because he disagreed with Obamacare's goals; more likely because the Administration's fumbling, bumbling, and rumbling threatened to prevent the law from accomplishing its goals.

The Washington Post reported Senator Baucus' changing opinion during 2013.   Early that year,  the Senator told HHS Secretary Kathleen Sebelius, “I just see huge train wreck coming down. You and I have discussed this many times and I don't see any results yet.” Later that year, the Post reported Senator Baucus commented (about the health-care exchanges and the government enrollment Web site) "Let's just see how much of this can be put together, how much Humpty Dumpty can be fixed, in the next month."

Well, hmmm.  Mmmaybe it WAS so bad, after all?  Even my Magic 8-Ball replied "It is decidedly so".  

I suspect Senator Baucus' deteriorating confidence in the success of Obamacare may have been a factor in his decision to retire from the Senate at the end of his term in 2014.  I also wonder if Senator Baucus' public criticism of Obamacare, especially his use of the descriptions "train wreck" and "Humpty-Dumpty," was a factor in prompting Mr. Obama to name him an Ambassador in 2014 and get him out of the country.  China, to be exact.

I think questions like these also help explain why history can be fun.