One Pennsylvanian’s Personal Experience With Multiple Health Insurance Systems & Their Outcomes

June 12, 2013

by Terry Jung of Pennsylvania

I have had a long career within both the public and private education systems, private computer consulting, and government employment with the Commonwealth of Pennsylvania’s Health and Human Services at the county and state levels.  I have also had periods of self-employment as an author and technical consultant, times of unemployment, and finally retirement with disability.  Throughout my career, I have experienced many different kinds of health care coverage.  With such variety in employment, the question should be asked, “What happened to my health care options and outcomes in each situation?”

Private insurance coverage offered through employers was always good coverage.  If a certain procedure was denied by my insurance company, my doctor had to file papers explaining the need for the procedure.  The procedure would then be approved, and the medical need was addressed.

Private insurance never dropped me even though my medical expenses drastically increased since FMS (fibromyalgia) is hard to diagnose, hard to treat, and impossible to cure.  I was never denied multiple specialists and treatment methods.

What I earned during the self-employment periods exceeded the income restrictions to qualify for state help with health insurance coverage.  Even though my income numbers looked good, the costs of hospitalization and frequent tests and doctor appointments decimated what I was earning.

During the time of unemployment, I had no health insurance.  Not once while I was uninsured did I have to go without quality health care.

I slowly began to manage my disease and returned to working part time.  My income was very low so I qualified for the Medicaid program.  I had to search for doctors who would take Medicaid; many doctors did not accept Medicaid insurance; even more have recently posted notices in their offices that they will no longer accept Medicaid insurance.  Since Medicaid pays health care providers much less than private insurance or cash payments by patients, finding a good doctor that accepts Medicaid is a challenge.  In addition, many of the drugs that had been established as necessary to manage my disease were not covered under Medicaid.  Changing to different drugs resulted in a medical set back for me.  I had to increase my hours to have enough money to pay for the drugs that had been established as necessary to my disease management.  In many cases, I had to do without treatments or medications under Medicaid.

Once I established the management of my illnesses throughout all my body’s systems, I returned to work full time.  My employer paid for my health insurance, and I was back to receiving quality care and medications for the full range of treatment methods.

After retiring, I was again uninsured.  My disability income had not yet been approved. My life was literally saved by the best specialists even though I had no insurance.

Once I had been retired long enough, my Medicare coverage began.  At first I had little problem with getting good health care and medication with Medicare plus a prescription drug program that I pay for.

When the Patient Protection and Affordable Care Act was passed, I was assigned a nurse practitioner instead of a doctor.  Thankfully I had had good doctors in the early stage of my disease so I had been taught how to take care of myself in terms of diet, nutrients, avoidance of contact with people, and doing my own physical therapy exercises.  Under Medicare, I have been denied cataract surgery for two consecutive years even though the doctor said the cataracts were ready for surgery.  I learned that if Medicare denies a treatment, it is illegal for the doctor to take cash from the patient to have the procedure done.  If the procedure had never been sent to Medicare, I might be able to pay cash for cataract surgery in both eyes, but I do not have the $6,000 for the surgery, and the surgical facility does not have a charity program.  Medications I had relied on for years were dropped from my Medicare coverage so I had to choose between paying for a drug myself or dropping the drug to leave money for bills, food, and other needs.  I can no longer drive.  My premiums have gone up in the last year, and fewer medications and procedures are covered by Medicare.  As more of the Affordable Care Act is implemented, more doctors are closing their practices, more hospitals are closing or being sold, and more penalties threaten health care providers.

In my long experience both while I was relatively healthy and when I had to manage a chronic, complex disease, I have learned that the best health care options were available to me when I had private health insurance or when I was uninsured.  Medicaid and Medicare both resulted in setbacks to my health for two reasons:  1) lack of access to quality health care providers who accept Medicaid or Medicare, and 2) restrictions on what procedures and medications are covered under the state and federal programs

If the goal of our health care system is to help people arrive at the point of death as quickly and painlessly as possible, then Medicaid and Medicare under the Affordable Care Act are certainly meeting that goal.  If the goal of our health care system is to help people arrive at early screening and treatment of diseases–curing them when possible–and to live out a full and enjoyable life, the flexibility of caring, competent health care providers in the private market must be recognized and rewarded.  I had the best care under private health insurance or while I was uninsured.  Medicaid expansion is a “for show” option–it makes the public think more of the poor are cared for when in fact health care providers are increasingly refusing to accept that insurance, leaving Medicaid patients with treatment options for minor illnesses but little else if a specialist is needed.  Medicare is plummeting toward that low goal and by 2020, will be even worse than Medicaid is now.  Seniors cannot give up Medicare insurance without giving up their Social Security income.  That is an unacceptable choice.

The best care we can give our citizens across the board is to allow them to work with health care providers directly to achieve good health care outcomes if private insurance is not available.  Let us stop pretending that government health insurance results in quality health care.  It’s time to rethink our health care outcomes and to be honest about how they are achieved.  My life was literally saved while I had no insurance at all.  I am sure I am not the only patient who has had such experiences, and that is a sad commentary on where we have allowed our health care providers and our patients to sink just so legislators can issue headlines claiming more people are helped when, in fact, they are not.  Please think again and talk to doctors and patients when making decisions.

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