Thursday, February 16, 2017

Seriously Depressed over the Inequality in Health Care

Given the number of Americans who suffer from mental illness in this country, we are failing miserably in caring for our own. The Affordable Care Act, aka ACA, or "Obama Care" was the first time the government had seriously looked at this national issue and made practical steps that offered help to the American public beyond Medicare or Medicaid. For those of you against the ACA, stay with me here.

Finally in 2013 the federal government implemented the Mental Health Parity and Addiction Equity Act (MHPAEA). This law, orginally passed in 2008, mandates insurance carriers have to recognize mental illness and substance abuse as the "illnesses" they are, and offer coverage equal to that of other "traditionally" covered illnesses. This, together with the ACA, gives every American the ability through the marketplace or private insurance, access to coverage for mental health and substance  abuse issues. Finally Washington has accepted the ugly truth - many Americans suffer from these illnesses and need help. 

My recent therapy brought this to my attention. Oh, for years I have seen a wonderful Doctor. Because I was blessed with really good private insurance this was covered. Well even with rich insurance coverage, I was only reimbursed 42% of the cost of each visit. Of course I was limited to 21 visits a year. (Keep in mind, Doctors will tell you, those who need serious help, require access to their doctor  twice a month or more often).There was no coverage for inpatient or out patient treatment.

After the ACA was passed and the MHPAEA finally enacted,  the amount of money I was reimbursed for each visit did not increase (due to my personal policy), however the number of visits allowed was greatly increased. (In fact may be unlimited but I am not sure about that.) Inpatient and Outpatient treatment was covered. However this is where, even given the great leaps forward, there is room for help. 

When I started Outpatient Therapy, my Doctor suggested 2 or 3 weeks. (Personally, I was hoping for 2 at most.) 2 or 3 days into it, I realized there were folks who had been there for 3 or 4 months and although they had made significant progress, they still (seriously) needed more therapy.

At the end of the week I was told a counselor would need to meet with me to complete a report for my insurance company. 20 minutes or so into the meeting, the counselor said, "I hate to tell you, but given your progress and how well you are doing, I am afraid your insurance company is probably not going to approve coverage for any more time." Knowing the cost of each day was $576, my paying out of pocket was not affordable. 

She continued, "I'm not saying you would not benefit from more time, but this is what we deal with every day with private insurance companies."

I thought for a minute, then I asked, "I know everyone's situation is different, but there are people here who have been in the program for 3 or 4 months. And not to judge, most are unemployed and don't strike me as folks who have this much money to pay out of pocket."

The counselor smiled. "This is what makes us so mad. If you are on Medicare or Medicaid, you are eligible for unlimited care. I am never required to do a report on those patients. However, I am required to do a detailed report for each patient on private or marketplace insurance each week in order to see if their coverage will be continued."


"Patients on private or marketplace insurance are only covered 3 to 5 days at most, even when they badly need additional time. Often 5 days doesn't even get us started." She paused, "So those who work and pay for, at least part of, their insurance or purchase it on the market place get extremely limited coverage. Yet those on Medicare or Medicaid get unlimited care. Don't get me wrong, I'm thrilled that at least some Americans are getting the care they need. But everyone needs access if they suffer from mental illness or substance abuse."

"Wow, I had no idea."

"Neither do most Americans, and Washington just doesn't get it."

When I first started the outpatient treatment I was hoping to be there as little time as possible. However several days into it I realized how valuable it was and how much I was gaining from it. When I learned that indeed the insurance company had decided 5 days was all I needed, I was disappointed. 

I will now step up onto my soap box. The ACA is flawed. I see it as a work in process. Doing away with it or greatly weakening it will reverse the progress this country, supposedly the greatest in the world, was finally doing to join most other civilized modern countries who ensure all their citizens are covered.

Oh, and one more thing, you may not be aware but all Senators, Congressmen, and the President have the best insurance offered in the country with the lowest co-pays, lowest rates, and best coverage. I know because for 18 years while I worked for the Federal Judiciary, I had access to that same coverage.

Therefore, I doubt they can relate to the rest of us when it comes to health insurance. So if you ever wonder why the US Congress and the President do not feel many Americans' pain with the lack of adequate coverage - they don't have to, literally. 

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