no allergy meds for you…

The American healthcare system is best compared to a sophisticated machine with many moving parts. A badly maintained Rube Goldberg to be more exact.

This post is going to be a little unusual for this blog. Typically, I don't spend a lot of time on healthcare other than trying to debunk pseudoscientific claims of homeopaths and vehement anti-vaccination activists from a scientific standpoint. But for the last month or so, I haven't been able to turn on the TV or look at a news site without hearing about some new uproar over a potentially major overhaul of the American healthcare system based on unfounded panic, astroturfing or stubbornly ideological grounds.

It really doesn't seem to matter that no one has seen the full and complete bill which may be voted on in Congress. In fact, those who oppose it are using this opportunity to grossly misinform the public and insist that should any change to the system pass, random bureaucrats will butt in between you and your doctor to decide the level of care you'll receive based on their schedule of costs, even though there's no blueprint for how the plan will actually work other than wild speculation and rumors coming from random pundits.

Now here's the really funny part about this threat. This is exactly what we have now. It's just that instead of a government official, we have a clerk from an insurance company decide whether we can get what our doctors prescribe us and our quality of care depends on who we work for or how much we're willing to pay. Let me give you a routine, real life example of how insurance companies interfere to prevent your treatment from exceeding how much they're willing to spend on covering you. Or in this case, me.

Friday of last week I went to my doctor because I've been having a little trouble with my allergies. He examined me and wrote a prescription for a well known medication with a slight stimulant. In theory, I should be able to go to the pharmacy, have them fill the script and allow my doctor's treatment plan do its thing, right? Actually, no. When I went to pick up my prescribed pills, the pharmacy says that the insurance company won't cover the prescription.

Instead, they want me to receive another version of this medicine and buy the mild stimulant it contains over the counter. I'm of course free to pay $185 for each month's supply and take what my doctor prescribed me but they won't do their job and try to cover my medical expenses because this medication is not as cheap as they'd like it to be.

All right, not a big deal. Happens all the time. I just need them to call the doctor who'll confirm that I really do need the medication he prescribed. A few days later, I come back to the pharmacy and find that while the insurance company did authorize the medication and the doctor confirmed that there was a real medical reason he recommended the medication he did and he's not just scribbling random expensive brand names on his prescription pad for the hell of it, it will only cover $40.

Why? There's a deductable on my plan and before they'll cover 80% of my medication as they say they will in their list of benefits, they want me to pay the whole deductible. If I want the medication that badly, I have to pony up $250 first. Or I could just comply with their wishes and get the pills they want me to take.

Now, I realize that you're going to say. I need a better insurance plan. And that may be true. However, to get the kind of plans offered by mid-size and large businesses for their full time employees, I'd need to pay upwards of $600 a month. If you're single and do a lot of freelance and independent work, that's an awful lot of money to shell out.

Without a spouse with a full time job and a good insurance plan, you're likely to end up with relatively sporadic coverage that gouges you for up to 50% of every procedure's cost until they get their deductible out of you. When you ask what you can do to counter the charges, you're politely told that it would be much more beneficial for you to get on a group plan or get a much more expensive one.

Here's the bottom line. If a doctor prescribes a medication based on his or her evaluation of your health concerns, you should get that medication without being gouged or blocked by an insurance company that doesn't want to pay for something they think is too expensive.

The only real way to get what you need without hassling with insurance companies and their immensely complex rules is to pay for it out of your own pocket. If you can afford to spend thousands and thousands of dollars on everything from prescriptions to tests, you can get some of the most advanced medical treatment any place you go. If you can't, you're stuck playing the insurance companies' game.

I've been told by health insurance experts that I just need to know how to work around the system, how to appeal decisions and with who to stubbornly fight to get my way. My response is that this complexity is totally unnecessary. You should be able to get the treatment you need when you need it and the way your doctor recommends you get it. You shouldn't have to outline plans to fight insurance company clerks who penalize you for being too expensive for their tastes.

And quite honestly, if we have a major overhaul of healthcare in the United States, the last thing I'm afraid of is some random paper pusher making decisions about the level of care that will be covered when I go to the doctor. I'm already dealing with that, even when it comes to simple allergy medication prescribed to millions of people every year.

Seems that the message of the groups opposing healthcare reform is that when the paper pusher in question is from the government, you're as good as dead. However, when he represents a company that makes more money by denying you a slightly more expensive but necessary medication and forces you to pay out of pocket for it, that's magically a-ok through the miracle of the almighty "free market."