I inadvertently gave myself a nice taste of the shit sandwich that is the proposed Republican Health Care Plan, Trumpcare, as far as I can tell from the details I’ve learned.  I heard an interview last night that laid out the main differences between Obamacare and Birthercare and realized– fuck, I did it to myself in 2017!  The Republican plan would greatly increase premiums, co-pays and deductibles on older Americans, an age-based pricing scheme not currently allowed under the ACA.  I’ve had a taste of that in 2017, hoping for better care than I had in 2016 I am paying 600% more for the same coverage I had last year.  You don’t need me to tell you what a shit sandwich tastes like.

Obamacare, basically Romneycare, which was in part based on the Heritage Foundation’s conservative plan to keep private industry in charge of American health care, had two or three major improvements over what came before.  In exchange for the mandate that would force younger, healthier people, on pain of a tax penalty, to buy insurance, thereby funding the pool for older, sicker citizens, American patients were freed from the industry’s “pre-existing condition” loophole and ensured delivery of what are deemed essential medical services.   It used to be possible to sell insurance with serious limitations on, say, preventative services.  No more, under Obamacare.

The details of the secret Republican plan, the culmination of a seven year partisan battle against Obama’s health care law, a law they’ve called “worse than slavery”, probably worse than any holocaust, were to be revealed a week before the up or down vote.  No debate was planned because Republicans, being in the majority, believed, at first, that they could pass the law on a strict party-line vote.  When some of the details were revealed, including the CBO report that 22,000,000 Americans would lose health insurance under the proposed law, the deal quickly went south.  It’s hard to cast a principled vote for something with a 12% public approval rating.  Even in today’s lockstep party-line political environment.

There were tremendous tax breaks to the wealthiest Americans as part of the Republican plan.  This would fulfill one promise the current president made to his wealthy friends and more than reverse the tax hike Obama instituted to help fund Obamacare.   Part of the Republican plan shifted more of the cost to older, sicker customers.  Another part removed the mandate but instituted an alternative punishment, a six month waiting period for enrolling if you allowed your prior coverage to lapse.  Under the Republican plan the customer would pay a higher percentage of the cost of medical care, from Obamacare’s 70/30 split to something much fairer to insurance companies, like 58/42.  A sixty-four year old with an income of $26,000, currently paying $1,700 a year under Obamacare, would see the cost of health care increase to more than $6,500 in premiums.   That number does not include increased co-payments and out-of-pocket expenses, devilish little details that could add up to another quarter of that person’s income.

Fatefully, the Republican plan would eliminate millions from the Medicaid Expansion roles.   Obamacare increased the threshold for Medicaid type coverage to people up to 150% above the artificially low poverty guideline and provided subsidies for people living on up to 400% over the poverty line.  11,000,000 to 14,000,000 Americans now have low cost health insurance that is virtually Medicaid.  

The costs of Medicaid Expansion are paid mostly by the federal government, the federal contribution is currently at 95%.  The Republican bill scales it back 5% a year from 2021 to 2014, until it makes the program impossible for states to continue.  States, under the Republican plan, would also be able to get waivers for in-state insurers to opt out of Medicaid expansion programs and offer less than the Essential Benefits mandated under the ACA. The Republican plan would allow patients currently receiving Medicaid Expansion benefits to be grandfathered in, but it is also still famously easy to be chucked off insurance, and once chucked, it’s chuck chuck bo-buck banana fana fo fuck to you for the rest of your earthly lifetime, under the Republican proposal.  The proposed bill also slashes funding for Planned Parenthood.  USA!   USA!!!!

I’ve written critically of Obamacare, which sucks in many ways, especially its fundamental deal to keep the foxes in charge of the sickening American health care henhouse.   That said, there is no question that it is more decent than the unfettered, bare knuckles medical insurance scheme that preceeded it.  People who receive coverage under the ACA, whatever our many frustrations with the idiosyncrasies  of the industry-written plan, prefer it to the way things were before.  Most Americans, it seems, agree.  

Is there still a serious debate over the “pre-existing condition” loophole that saved insurance companies billions while condemning countless sick Americans to death?  Even Mitch McConnell’s bill doesn’t restore an insurance company’s right to refuse to sell insurance to somebody because they once suffered from an expensive medical condition.

It seems apparent that a big part of the motivation for this Repeal and Replace mania is a vicious partisan hatred of this nation’s first mulatto president.   There’s greed by the wealthiest, sure, you always expect a certain amount of that from wealthy materialists obsessed with getting every government advantage to help them become wealthier.  There’s the old partisan bickering that has become a larger and larger feature of our political landscape since Reagan.  

To understand the Republican jihad to repeal Obamacare we must not discount hatred, pure and simple, of the well-spoken half black man for whom the bill is named.  He comported himself with dignity even as Mitch McConnell announced that the Republicans were dedicated to making sure everything the president proposed failed and a coyly racist movement known as Birthers publicly, continually and counter-factually attacked Obama’s legitimacy to be president.  The highest profile “birther” was the celebrity brand who is the president now.

 “Birthers” spoke the lingua franca of millions of Americans, and said it loud and proud: “this man is a nigger and we do not have to have a nigger president of the United States.  We will simply not allow ourselves to be ruled by a nigger.”  If you doubt this widely shared sentiment, look at a large part of the current president’s base.  Millions of readers of websites like The Stormer, named in homage to the Nazis infamous Der Sturmer, whether affiliated with a hate group or not (and these mothercuckers have proliferated wildly since Obama’s election) will have no problem endorsing this view.  I guarantee that not one of these neo-nazi fucks will ever use the politically correct “n-word” to refer to our former president, except perhaps in gleeful air quotes.  These angry young white men, and their fathers, and grandfathers, voted overwhelmingly for the race-baiting panderer-in-chief, an unrepentant leader of the Birthers.

Are we living in Germany 1938?  I’d like to think not. On the other hand, on the eve of Hitler becoming the full-blown Hitler history remembers, the New York Times opined that the institutions of German democracy were too robust, the German people too cultured and sober, to allow the crass little shit-snot Mr. Hitler to run amok.  Run amok the crass little shit-snot Mr. Hitler did.  I’m not comparing this genius of audacious self-branding to any other would-be tyrant.  I’m just sayin’.   The proposed repeal and replacement of Obamacare would be a giant step toward the final victory of America’s crass little shit-snot-in-chief and the third of the nation on which his legitimacy stands.  

Would it not?

Long before he ran for president, Senator Bernie Sanders told national treasure Bill Moyers “the business model for Wall Street is fraud.”  It is hard to dispute this description, even as the law winks at and lawmakers and other canny investors profit from the business model of Wall Street.   The business model for American health insurance companies is fraud.   Their profit is based, in part, on their ability to deny services that customers pay for.   I offer the following maddening illustration.

Leave aside the debate over if it was fair to make insurance companies offer reasonably priced coverage (or any coverage) to people with ‘pre-existing conditions.’   I’d argue it is fair, but fuck my opinion.   You can argue whether it’s fair to make insurance companies, collecting decent premiums from consumers, cover an annual preventative visit to the doctor.  You can argue the fairness of it, it’s your absolute right as an American to argue.  You can even elect a living turd to bully his party into dismantling the timid, conservative think tank-created baby step in the arguably right direction for ‘failing American health care.’  I’m here only to point out a concrete instance of the basic business model of American health insurance: fraud.

You are faced with a single choice for treatment of, let us say, chronic kidney disease.   You are being strong-armed toward the one treatment available to medical science:  immunosuppressive therapy, a kind of chemotherapy described as an “atom bomb that knocks out your entire immune system and hopefully straightens out your auto-immune disease when the immune system comes back on-line.”  The treatment involves IV steroids and other agents with possibly severe side effects.   On the other hand, one third of all sufferers of this mysterious disease are cured from it without medical intervention.   Nephrology does not have a clue about this “spontaneous remission”. You seek a second opinion.    You’d like a medical opinion about how to increase your chances of being in this one third who recover from the disease without undergoing a form of chemotherapy.

The only opinion you will get from an American nephrologist is that immunosuppressive treatment is the only medical treatment currently available, and that you’d probably be wise to start before you suffer permanent kidney damage.    You hope for a thoughtful nephrologist, who will not prey on your fear but allow you to make a fully informed decision about treatment, but the rest is a matter of the chance and the doctor’s personal style, whether they listen well and answer questions, return calls, are supportive or dismissive, sensitive or prick-like.  The one I happened to see was a jerk.  Luck of the draw.

Anyway, better still, let’s leave aside the specifics of the case.  To see an out-of-network provider, paid in part by the insurance company, you need to obtain pre-authorization for the visit.  This pre-authorization is granted , based on medical necessity.  The insurance company gives you a number for the doctor to call to get pre-authorization.  They must convince the Medical Management department that the services they provide are not offered by anyone in-network.

Once the case is made, Medical Management renders a determination.  A week later you learn whether or not the visit will be partially covered by insurance.  Without pre-authorization insurance will never pay anything towards the visit.

Provider calls Medical Management.  They are told that the patient they are calling about does not have coverage in his policy for out-of-network visits.  No request for pre-authorization can be made on behalf of that patient.  Thank you for calling, the end.

When the patient is informed of this, and calls the member’s services number at the insurance company, he is told that he does have coverage for out-of-network visits.  The problem, he is told is that the provider did not have pre-authorization.

You point out that the provider called the number you were given to get pre-authorization.   Perhaps they are referring to some pre-authorization for pre-authorization you have not been informed of.   Or perhaps, since they have told the prospective doctor a plain untruth, which forecloses the request for pre-authorization, their business model is closer to fraud.  If you have the ninety minutes to devote to this discussion, and sufficient patience and skill, you can get it worked out and the provider can submit a request for pre-authorization.  For virtually everybody else– bingo! we just made some more money for our CEO.

You get an Initial Adverse Determination from the insurance company.  There is no need for this esoteric specialist, it informs you, when we can provide you a dozen in-network doctors with the same expertise as the doctor who did not answer your questions, the one you don’t want to see anymore.  

You call the insurance company to ask them what the hell this determination means, as it makes no mention of medical necessity or the argument presented, it merely denies the pre-authorization based on the fact that they have many specialists in the same field, as well qualified as the jerk you no longer trust to give you medical advice.

Here’s the kicker, though.  Membership, the only number you can call, as a member, has no record of any request for pre-authorization or any determination affecting you, adverse or otherwise.   You read to them from the determination you are holding.  They seem to believe you, they just have no record.   You are, of course, free to appeal the Adverse Determination, in fact, you have, under state law, a generous 180 days to do this.  They are Member Services, after all, only the Provider side has any of this information.  

It happens again with the next doctor.  “This consumer has no coverage for out- of-network visits, thanks for calling.”  Now it is a pattern, a pattern and practice.  It is part of a fraudulent scheme.  Only my opinion, of course, but can you think of a word that describes this better than fraud?    

“Did you try calling the Provider number?” suggests Sekhnet, thinking outside the box.

I do.  I am patient, I am persuasive, I do not pretend to be a doctor, I state my case.  The representative is understanding, tries to be helpful.  Her hands are pretty much tied.  She speaks to a supervisor.  Tells me only Member Services can help me.  I describe the fraud again succinctly.  She does not disagree with my description of the ingenious scheme that separates these two parts of the corporate brain.  She asks me to please hold while she speaks to another supervisor.  I listen to the hold music for a few minutes.  She returns with helpful news.  

“You can ask for an EXPEDITED APPEAL,” she tells me happily.  The regular appeal takes at least a month.  I ask how long the expedited appeal takes.  She has no idea, but I can find out at Member Services, she believes.  She can transfer me there now, she tells me for the sixth time.

I rest my case, over and over again, on my own head.  I’ve got to finish that fucking letter to the New York State Attorney General, the one who got the current president to cough up a token $25,000,000 to settle the case against him for his fraudulent university.  New York State needs to regulate these lucrative, legally created pseudo-person psychopaths.