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Over the winter holiday, without any prompting from me, my cousin* started talking about the problems with our healthcare system. Does that sound likely? No, of course not. She started talking about healthcare because I asked her about it over and over. But until she punched me in the arm and insisted we change the subject, I learned some interesting facts.
My cousin recently started a new job, and with it came a new health insurance plan. She has a minor neurological condition, but she thought that, since she moved directly from one job to the next, she would not be excluded from her new health plan. This, after all, is what the fabled COBRA coverage was designed to provide.
But it seems that some of the HMOs have evolved certain mutations that make them resistant to COBRA. When she tried to go see her neurologist, she was informed that she wasn't allowed because her insurance was severely restricted. Why, she asked? The reason was that four years earlier, she'd had a three-month gap in coverage while between jobs. Due to her lack of "continuous coverage", she only was given limited access to services.
What does this mean for my cousin? It means that for the next 18 months she is only allowed to see her primary care doctor. She gets one annual visit, and after that she has to pay out of pocket. No neurologist, no ob/gyn, no other specialists. They will cover life-threatening emergency room visits, but not common-sense preventive care for her neurologic condition.
Let's say her condition acutely worsens and she is forced to see specialists. She could be bankrupted by the repeated visits to the doctor that she will have to pay for. But if her condition had worsened a year earlier, it would have been covered by the insurance. Does this make any kind of sense?
Another point: is it really ethical to restrict a young woman from seeing an Ob/Gyn for 18 months? Yearly Pap smears are pretty much accepted as standard of care. Even the doctors employed by Aetna wouldn't try to argue that point. So how can they have a policy that prevents an "insured" 32 year-old from seeing an Ob/Gyn? (Perhaps this is an added argument (if a perverse one) for why all internal medicine docs should be well-trained in pap smears).
The insurance company's argument in response would be something like this: "During that three-month gap in her coverage, she may have developed some condition which we cannot bear the financial responsibility for." Yes, who knows what crazy hijinks she got up to while she was Off The Grid? Everything will change after 18 months, of course. They'll have her all fixed up and spit-shined, and then she will be offered the full spectrum of first-tier HMO services.
The system is illogical and, as always, no single person is responsible. It's the impersonal nature of the cruelty that makes reform so urgent.
*not her real relationship to me
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