Dear Mr. Attorney General:

I am appealing to you for assistance, on behalf of many thousands of New Yorkers caught in a sometimes life-threatening situation regarding their healthcare.  As described more fully below, citizens of our state have no government agency that intervenes in cases where patients are mistreated by the corporations we buy health insurance from.   This is true even in cases of apparent fraud.  

I urge you to propose legislation to correct this grave oversight.  The need for state regulation of health insurance grows ever more acute in light of the current federal administration’s determination to gut all regulation.

I’ve followed your career and admire the principled and proactive steps your office has taken against the powerful perpetrators of various frauds.  Leaving politics aside, as one must in a letter like this, it is gratifying to see someone in office holding powerful entities responsible for their bad acts.  Your office is well-suited to fix what I believe is a healthcare emergency affecting the lives of countless New Yorkers who purchase private health insurance, particularly older citizens and those living just above the “poverty line.”

As frustrating as my healthcare-related ordeals have been, a 61 year-old currently trying to get treatment for kidney disease and skin cancer, I have the benefits of fluency in English, computer literacy, legal skills.  It is hard to imagine the life-shortening stress that is inflicted on the elderly and other vulnerable New Yorkers unable to get so much as a hearing for often unappealable denials of health care.

It has been a challenge to put the many healthcare-related issues I’ve been forced to navigate into a streamlined letter.  I’ve attempted to keep this letter short and dispassionate.  To that end I provide some of the devilish details in a series of attachments.  I have confirmed many times that my experience as a consumer who buys health insurance on the New York State of Health Marketplace (“NYSOH”) is representative of the experiences of countless others.  

Attachment # 1 is a detailed description of the “consumer help” cul du sac that desperate NYS residents can spend a few hours in, looking in vain for help with health insurance-related troubles.  Anyone in your office can retrace the useless steps.  Creating a healthcare ombudsman position would be a good first step here.    

Corporate “persons” are without conscience and motivated only by a zeal for profit.  When left unregulated, it is no surprise such “persons” act as they see fit.  In the case of health insurance companies, they are free, for example, to repeatedly refer patients to “in-network” doctors who are not actually in-network.  They are also relatively unrestrained when refusing to provide services, under a variety of corporate rationales, in spite of what the Patient Protection and Affordable Care Act (“PPACA”) may have to say about it.   There is no penalty for these common business practices and they are well aware of it.  Regulations to address these things, with an enforcement arm, would be a good start.  (see #2)

Those mandated by the PPACA to purchase health insurance from the New York State of Health Marketplace may find themselves with a host of new problems during the short holiday season window for purchasing insurance. A consumer advocate or ombudsperson on site at NYSOH would greatly aid in resolving problems, including simple mathematical errors, that presently can only be addressed by a lengthy appeals process.  (See  #3)

Billing irregularities, including improper bills, which are to be expected in a law as complicated as the PPACA, are probably the most common form of immediate stress most of us are regularly subjected to.   The rep at your office’s consumer help desk offered help with billing problems, problems I suspect are legion.   I offer a short overview of the larger problem and one recent snapshot as #4.

Thank you for your time.  I am available to amplify anything written here and to testify anywhere you may require.

Yours sincerely,

From attachment 4:  

The PPACA, whose primary drafter, Liz Fowler, went back to work in the health industry after her legislative work was done, apparently contains no provision that the cost of a medical service must be divulged to the patient before the medical service is performed.  

The doctor’s office or hospital cannot tell you the fee until the insurance company sends them a statement.  The insurance company cannot predict the fee until they get the provider’s bill.  The insurance company then eventually sends the patient an Explanation of Benefits, (“EOB”), detailing all charges, payments made and the patient’s responsibility for whatever part of the negotiated rate insurance has not paid.

My kidney biopsy, for example, may cost the patient anywhere between zero and many thousands of dollars.  Simply no way to determine the cost prior to delivery of the service, under current law.  I had the procedure on May 26, I got the most recent EOB related to the procedure on September 28.  In the intervening four months, I got many bills from the hospital.

Though there is probably nothing your office can do about this particular practice, I offer it as an illustration of the scope of the challenges facing New York healthcare consumers.  I provide the following (obviously minus preamble, dear reader)  as a snapshot of the general billing madness under our current regulatory scheme.   I compare it to eating at a restaurant with no prices on the menu, and being sent a bill for the meal weeks later.  Except, of course, that it is not a meal at a restaurant, it is often a matter of life or death.