Category Archives: Obamacare

45,000 dead Americans

What do you call 45,000 uninsured Americans who die every year for lack of medical care in the wealthiest country on earth?  

The price of freedom.  The cost of doing business in the Free Market, bitch.

At the risk of seeming to pile on the president I voted for twice, a charismatic man beloved by millions even as he killed American citizens by remote control without trial or charges (and gave that power to his unstable successor), even as he repeatedly lied about “transparency” and prosecuted those who exposed government abuses under a draconian law drafted in the hysteria leading up to American entry in World War One, a law designed to crush dissent, even as he did much for the wealthiest among us and little for the rest, while delivering inspiring speeches at every turn– I have to say, I really do hate the motherfucker.  Someone with his intelligence, expressed ideals and talent as an eloquent and convincing salesman should not be such a tool of the status quo— in my opinion.   Yes, I know, half of Congress are not unsympathetic to the Klan and all that, rabid partisanship and racism are off the hook and so on, but, still.

“If you like the doctor you have, you can keep your doctor,” was, of course, POTUS-speak for “I won’t come in your mouth.”  Most of us make promises in the heat of the moment, sometimes it’s hard to keep them, I certainly understand that.   The side-effect of this untruthful statement, for me, the deal sealed by the immensely complicated PPACA drafted by the affiliated American medical industries, is that I’ve had to change doctors several times, pursuant to changes in the ACA in New York State in recent years, though for years I had good doctors I liked and was able to easily see.

Slipping through the cracks the last couple of years, as I’ve been forced to change networks and doctors more than once, and largely my own fault, was a visit to a dermatologist for a skin scan.  I almost saw one a year ago, paid for the visit out of pocket, though I also had insurance.  What scared me were the unforeseeable lab costs and possible follow-up surgery costs.  In hindsight, very stupid.   I’ve already had skin cancers removed from my nose and my arm.  Why am I fucking around?

In less than an hour yesterday I was able to find the names of dermatologists (“providers”) who accept my current QHP (“qualified health plan”) and rule out one who appeared, by the many similar comments about him on the web, to be something of a complete asshole.   A young woman dermatologist in a nearby office seemed like a good bet, nothing good or bad about her on the web.  Clicked on her office to make the appointment, typed in my insurance and was notified:

 

out of network.JPG

After only twenty minutes on the phone with the insurance company I was assured that the doctor is definitely in-network for my QHP.  The woman at the insurance company sounded very confident, offered to call the doctor’s office for me and make an appointment, but it was already after hours.  

I called today to make the appointment.  I gave all my information and when it came to insurance there was a pause.  The doctor is not enrolled in the QHP with that insurance company.   I explained that I’d been referred to the doctor by the insurance company’s provider look-up, verified with the insurance company that the doctor was in the plan.   She asked me to hold and as I did, the Dr. Mengele String Quartet sawing away at an adrenaline-fueled classical piece scored for the highest registers of their instruments, I felt my blood begin to boil.

I calmed myself with the thought that it is truly nothing personal.  45,000 Americans will die this year for lack of medical treatment.  Some are fuck ups who just don’t go to doctors until their symptoms are overwhelming and by then it’s too late.  Some have no health insurance and are scared by doctor and hospital bills.   Some are just fucked.  No reason to take any of it personally.  There is nothing personal here.   I am no more special than any of the other tens of thousands of Americans who will die this year because profit for a few is deemed much more important than the lives of  enough American losers to fill a large stadium.  Fair enough.

The thought didn’t calm me that much, though.   When Melanie came back on the line she told me she’d contact the office that coordinates the dozens of insurance companies and QHPs the provider group currently participates in.   She said it was possible that the doctor had recently been added and that they hadn’t updated the system yet.  

I was relatively restrained in giving Melanie a succinct and dispassionate version of what I have written here.  Melanie was nice, she has offered to call me tomorrow to follow-up.   As I sit in the chair tomorrow on the last day of a multi-visit root canal I will think of Melanie, ready to call her as I stagger from the dentist’s office.  I will keep my fingers crossed that none of these things growing on my skin are anything to worry about.  Then I will continue my search for a participating nephrologist for follow-up about the progress of my kidney disease. 

Consumer info for people screwed by The New York State of Health

I post this as a public service for New York State health insurance consumers at the mercy of the merciless New York State of Health Marketplace.  

The identity of the person responsible for the public “marketplace” where otherwise uninsured New York State consumers are mandated to buy health insurance is a closely guarded secret within that public agency.  Representatives of the agency are forbidden to disclose the identity of the executive director they work for.  I have confirmed many times over that this is the actual policy of this public agency.  

The likeliest reason for this policy of secrecy is that she doesn’t want 1,000 overwrought letters a day complaining of the mind boggling, blood boiling, heart attack inducing inefficiency of the bureaucracy she oversees.  And who could blame her?  Would you want your secretary bogged down with an endless tray of badly written complaints?

Fortunately there was a letter to this elusive public official posted on the internet.  Here is the unaccountable political appointee’s contact information:

Ms. Donna Frescatore 
Executive Director 
New York State of Health 
New York State Department of Health 
Corning Tower 

Empire State Plaza Albany, NY 12237

Drop her a line, please give her my best.  

And as they tell you at the New York State of Health Marketplace, after a long call that fixes nothing, thanks for calling and have a nice day!

And as I answered today, through gritted teeth, after a 20 minute exercise in self-control to pronounce the word “yes” to the person in the proper office to confirm that I still wanted the appeal I asked for a month or two back, “it was my pleasure.”

In Fairness to Barack Obama

Let me try to be fair, for just a moment, then back into the trenches, snarling.  No, that sentence betrays too much, doesn’t seem fair, or balanced.  Let’s wind it back a bit, shall we, make it a little more personal?    

I voted for Barack Obama twice.  The first time I was actually optimistic that he might be the capable agent for overdue change he presented himself as.  The second time I voted for him on the theories of “fool me twice, shame on me” and the old chestnut of casting a vote for the lesser of two evils.   Evil, surprisingly, has become a relative thing in our desperately polarized society.  Mel Brooks’ genius definition of tragedy and comedy comes to mind: tragedy is when I break a fingernail, comedy is when you fall down a manhole and die.   Evil is now seen as who is doing what to whom and how does it affect me directly?  

We have been living for a while in increasingly partisan echo chambers.  In one chamber we find it absolutely sickening that obstructionist politicians can brazenly ignore their Constitutional duties when it is politically expedient and offer ‘explanations’ that sound startlingly like “we don’t have to do shit because this illegitimate Muslim non-American is a fucking ‘n-word’.”  This was the position publicly stated (sub silento, as they say, dog whistled) by Mitch McConnell and other prominent Republicans when Obama took office: our goal is to make him a weak one term president who can’t get anything done.  True we can’t lynch him, but we can certainly fuck him up and erase any legacy he tries to leave behind as soon as we get rid of him.

In the other echo chamber there is little question that Barack Obama was an insidious Kenyan-born Muslim intent on destroying America at all costs.   There is no doubt that he is a Negro, the son of an African from Kenya, that’s something even Hussein Obama himself cannot deny.  Many who hate Obama are undoubtedly racists, others are just, to be fair and charitable, skeptical of any Democrat who speaks well, appears thoughtful, ponders nuance, displays charisma and does not openly support the urgently needed policies they hear called for on talk radio during a time when terrorists are killing one out of every five Americans on a daily basis and violent crime plagues our once-great nation as it is overrun by hordes of threatening non-white aliens.   To be even more fair, some in this right wing echo chamber are just decent wealthy people who reasonably fear a loss of income from any policy that protects the weak at the expense of the wealthy via marginally higher tax rates.    

The divisions in our country, and the deep corruption of our pay-to-play lobbyist-driven political system, resulted in the election of a vain demagogue who seems completely unencumbered by principle, outside of increasing his own wealth, fame and power.  During the presidential campaign he promised to repeal and replace Obamacare.  He promised to create a terrific health policy that would protect every single American, not including, of course, the millions at his own rallies that will be without health care once he rams through the urgent repeal of Obamacare and restores large tax cuts for the rich.  While giving no specifics, he assured the gullible that his plan would cover all Americans, cost less and deliver much better health care.  He often ended this promise, like so many honest people reflexively do, with the tagline “believe me, believe me.”

I don’t like to think we live in a stupid country.  I prefer to think we live in a cynically manipulated country.  There’s a lot of money in cynical manipulation. The genius of America, if I may modestly say so, has long been cynical manipulation.  Look, we had this great continent with vast natural resources and incredible wealth.  There were savages living on it, attacking our settlers, impeding our ability to exploit all this wealth.  Manifest Destiny, et, voila!    

I don’t like to think we live in a country that could easily return to a lynch mob mentality, even with the increased crowing of White Supremacists and the recent surge in hate crimes.  I prefer to think we live in a country where, during desperate times, the homo sapiens fear and rage-driven instinct to mass violence sometimes understandably occurs.  Americans are no better, or worse, as a group, than the far away brown people we kill by remote controlled drones.  Americans are fair people, to the extent anyone can be fair in a world like ours.  

The plan the Republicans have slapped on the table to replace the conservative, corporation-friendly health care compromise that critics called Obamacare and vowed to repeal over and over while our nation was ruled by that tyrant, should not pass the sniff test.  It includes billions of dollars in ‘tax relief’ to the wealthiest 2% while cutting millions of low income Americans off health insurance, or making it completely unaffordable for those who had no option before Obamacare.  

In a better world somebody would just buy some TV time, invite Paul Ryan into a pay-per-view boxing ring, and simply whip the snot out of that snotty intellectual, settling the matter once and for all.  Ryan is an intellectual in the same way that a four foot tall man is a giant in Lilliput.  He read at least one very long book, a novel he bases his political philosophy on.  That he is driven by principle is reflected in his ongoing refusal to cooperate with Mr. Trump, the candidate he thoroughly repudiated during the campaign. 

I began this piece in fairness to Obama.  Here is that fairness, the PPACA is better than what existed before.  The PPACA is a deeply flawed compromise that left greedy corporations in charge of most of health care, sure.  But in fairness, it contained a few good and long-overdue things; eliminating the obscene ‘pre-existing condition’ insurance loophole, extending affordable health insurance to millions, focusing on cost-saving incentives based on preventative care, saving the lives of some of the thousands of Americans who still die every year for lack of affordable medical care.  The big flaw was that it left the gorged, rabid foxes in charge of the henhouse, but we can’t let the perfect be the enemy of the demonstrably better than complete shit, can we?    

Americans like the ACA, particularly those who were uninsured before the law took effect, even if many raise their torches and pitchforks and scream for the overdue repeal of tyrannical Obamacare.  That’s OK, at Tea Party rallies Americans angrily held signs telling the government to keep their evil hands off Medicare.  

I don’t like to think badly of my fellow Americans.  I am counting on the stink of this bill, hastily prepared and designed to give money back to the richest Americans who the Kenyan Muslim simply mugged like the common criminal they always said he was, to ensure it does not get out of the House of Representatives.  There are political maneuvers available to a party that did not hesitate to shut down the government when that Negro president insisted on trying to be the president, but the backlash should be too much to allow their use.  

On the other hand, the spineless opposition party is mostly blowing bubbles of saliva so far, and making those humming sounds you sometimes hear in a Special Ed class.  Don’t forget, they depend on the same billionaires who supported Trump for their reelection campaigns.   I guess the odds are 50/50 this big winner gets to win again.  Who among us will be surprised if a few million losers lose again?

 

Medical Care American Style

At the risk of coming off like Lenny Bruce obsessively reading from his trial transcripts, as his legal ordeal continued and his heroin use spiked, I have one more, hopefully quick, take on the crisis in American health care.  Tying health insurance to a full-time job with a reasonable wage (and creating as many loopholes as needed to avoid offering health insurance at all) is part of American Exceptionalism, like the wonderfully acronymed COBRA that can be purchased by those fired from jobs to continue to have full-priced health insurance.  Tying health insurance to full-time work guarantees America a fairly docile work force since, if you lose your job you can’t afford COBRA and you’d better not have any health problems.  It also allows the nation’s largest private employer, Walmart, to employ a vast non full-time workforce it does not have to offer health insurance to.  Luckily for those employees, many are so minimally paid they qualify for Medicaid, a government plan for poor people paid for by all other taxpayers.  

While the zealots of the majority Freedom and Liberty party vote on party lines to gang bang and strangle Obamacare, with a much better, if very hastily drawn, plan that ensures the rich will get richer and the weak, ill and lazy will no longer be able to exploit the Kenyan Muslim’s overly generous health care plan, I am beginning to try to straighten out hospital bills for a brief mid-November stay, bills I began receiving between Christmas and New Years.  As the bills came in I was still wrestling with the giant anaconda of the New York State of Health Marketplace and its mandate to reapply for insurance between the week before Christmas and two weeks after New Years.  If you have never experienced that ‘marketplace’, God bless you, and be extra nice to your boss.

Last summer my new Obamacare doctor flexed his muscles to show me what a healthy heart muscle was like and then let his arms droop to show me what my dilated left atrium, one of the four chambers of my heart, was like.   He promised to refer me to the cardiologist who was to set up a practice in his office in the next few weeks and told me not to worry as long as I had no chest pain or shortness of breath.  Not long after that I had chest pains while riding the bike up a hill and decided to wait to see the cardiologist before staying in shape with biking.  

In fairness to my doctor, I only followed up about the new cardiologist a handful of times over the next few months so he is not 100% to blame for the escalating untreated concern about my heart that I was having.  Following Sekhnet’s alarm and this doctor’s advice, one November night I checked into the nearest Emergency Room with enough symptoms and risk factors that they admitted me to the hospital.  

Of course, because the ACA allows doctors, hospitals and insurance companies to opt in and out of the plan, the hospital I went to, and the doctors I saw there, were under no obligation to accept my insurance.  As far I knew, under the PPACA, Emergency Room visits were covered, then again, my fully covered colonoscopy a few years earlier had left me with hundreds of dollars in medical bills– lab fees, they insisted, were not covered, nor the almost $200 for the mandated pre-visit to the provider who performed the colonoscopy, according to the lawyers letters I received.  

After a brief overnight hospital stay and a stress test the following afternoon I was cleared for strenuous exercise and have been working myself back into some kind of cardio health so I can do the 40 mile Bike NY ride with friends in May.  

My follow-up with the cardiologist on December 15th was abruptly cancelled mid-exam.  There was some question, the unethical cardiologist explained, about his getting paid by my insurance carrier for the visit.  Walking back home on that frigid day I stopped by the hospital to let them photocopy front and back of my insurance card.  I wanted to be sure they had the current insurance information correctly in their system, since I’d been obliged to change insurance, and doctors, multiple times in recent years.   I followed up with the hospital’s offsite billing department and was told there were no charges pending.   A week later a blizzard of bills began arriving.    

I’d estimate there are now more than two dozen bills, some explaining what they are charging for, others less exact, others threatening me with legal action for unheeded second and third notices.   I finally called yesterday about a bill for $810, the cost of the stress test.  At the bottom of the bill was printed BCBS Health Plus, the name of my insurance carrier and plan.  The woman at billing asked for my ID number in that plan, a plan I no longer have.  I read it to her.  

She checked her computer and told me no bill had ever been submitted to the plan typed at the bottom of the bill I was holding.  She told me she had just submitted it and that it would take four to six weeks to hear back from the insurance company.  She also informed me that her office did not deal with Emergency Room or other hospital bills, only physician’s services, and gave me the number for another office.   In the meantime there was nothing she could do to keep the automatically generated doctor’s bills from being sent to me.   She suggested I just ignore them until I heard what BCBS had to say.  

I will do that, as I will ignore the letters from the hospital’s lawyers informing me of their collection efforts.

While I wait to see what these lock-stepping bullies in Congress decide to do to give the very best health insurance to our nation’s most vulnerable citizens.

God bless these exceptional United States!  God bless us a lot.

Legislative Fix

We often complain about problems, with little ability to do anything about them.   This is particularly true in the area of politics, which while always local, is increasingly controlled by psychopaths, many of them not even persons, except in a convoluted legal sense, thousands of miles away.  I don’t want to get started on this issue of local sovereignty, because I have a large fish to try to figure out how to fry (proposing needed legislation for the publicity hungry AG to propose), but just a toe-dip into it before I begin.    

When the slave states seceded from the Union in the months before Lincoln was inaugurated, their issue was “states rights”.   In many areas; criminal law, family law, business law, each state is its own sovereign, by the design of our republican government.   Under our law community standards govern many things, like what is or isn’t pornographic. [1]   This is why the federal government had to step in after the Civil War to ensure community standards weren’t imposed on people who had been slaves a year or two earlier.

The “states rights” argument has most often been used by right wing types to claim exemption from federal meddling.   “We know best how to handle our own damn Negroes and don’t need you meddling liberal troublemakers coming down here telling us how to treat them,” as indignant southern states rights advocates said for decades, while standing on the same principle to prevent debate on federal anti-lynching laws.   

Of course, now that we are living in an open corporatocracy, certain universal rules are required for maximum profit.   The doctrine here is called “federal pre-emption”– on certain extremely important issues where a uniform national law is necessary, federal law preempts the wishes of the state and locality.  

Organic farmers in local communities, for example, had better shut up about pesticides and pesticide-resistant genetically modified crops, because the Supreme Court is about to sign off on Monsanto/Bayers’ right to sell their products everywhere with no interference from local bigmouths.  Same goes for marijuana, your local preference for a moderately harmless drug of choice has nothing to do with Nixon’s 1969 federal classification of the drug as a dangerous narcotic with no medicinal uses in his infamous Controlled Substances Act (“CSA”).  The CSA allows federal prosecution of pot smokers and the arguably arbitrary imprisonment of countless Americans in a decades’ long war against “Drugs”.   Same goes for anything we say it goes for, ass wipe.

One right-wing, states’ rights objection to the conservative private industry-protecting Patient Protection and Affordable Care Act is that the federal law mandates the purchase of health insurance by millions of newly eligible citizens.   Takes away the right of the local government to decide how best to protect its disposable class of asshole citizens too stupid to have corporate jobs, or public sector ones, that provide health care.  

But enough of the critique of the easy to ridicule right-wing, I’m here to propose legislation to fix a specific problem: 

that NYS insurance companies routinely deny healthcare services to mandated low-income health insurance buyers utterly unprotected by New York State law, in spite of the fig leaf of administrative supervision by the Department of Financial Services.

Just before New York State adopted the Patient Protection and Affordable Care Act (“PPACA”) it abolished the New York State Insurance Department and removed all traces of oversight from the New York State Department of Health.  The functions of these agencies were merged into the New York State Department of Financial Services.  This agency has sole responsibility in New York State for oversight of health insurance companies, as well as all fraud investigations related to consumer fraud against insurance companies, and all complaints about the practices of financial institutions, banks and brokers.  

Everything but, according to a fraud investigator for the Department of Financial Services, who referred me to a non-responsive phone tree number, investigations into colorable fraud committed by insurance companies against mandated health-care “consumers” in New York State.

Granted, the PPACA was written by health industry insider Liz Fowler.  It is only sensible that it tilts toward protecting industry profits over the rights of individual patients.   In light of this, it is a grave oversight, and a direct threat to the health of its most vulnerable citizens, that New York State does not have an independent agency dedicated to resolving the countless daily denials of purchased health care services. The need for this agency is particularly acute now that we have a president determined to eliminate most government regulation of private industry.

A health insurance consumer in New York State looks in vain for a forum where these complaints can be adjudicated.   At minimum a well-staffed Ombudsperson’s office should be created– and the 800 number prominently displayed on the New York State of Health Marketplace homepage.  Consumers of mandated health insurance in New York State should not be subjected to the arbitrary abuse of power by unaccountable private corporations whose primary business is increasing their profit margins.  

Proposal: create an agency dedicated solely to enforcing the rights of defrauded health insurance consumers in New York State.  

I mean, seriously, dude, how hard would that be, in the looming age of Trumpcare?

 

[1]  The Supreme Court recognizes that what is titilatingly pornographic to a hipster from Brooklyn might actually induce vomiting in someone from Kenosha, Wisconsin.

Note on Son of Letter to etc.

Interesting to notice how the unconscious mind grapples with a seemingly unsolvable problem.  When you are under ongoing stress from a difficult to bear psychological torment the brain struggles against it in the background, I suppose.  Objectively, your situation might scream for relief– anybody in your position would be ready to start shouting, particularly if there is no possibility of relief.  

The way things are set up here in the Free Market, you’d better have a lot of money to buy influence if you are burnt by something that desperately needs changing.  I have been banging my head against repeated drafts of a letter that has, at best, a small chance to influence even NY State’s publicity hungry AG to take action.  First a bit from the trenches:

My Obamacare navigator (the “in-person assister” who helps consumers find their way on the opaque New York State of Health website) was on the line with me Monday when I called to get my subsidy reinstated.  The quickest way to resolve this situation is to simply run my numbers again and calculate the subsidy the law entitles me to.  

This, I learned, will be impossible to do, according to the New York State of “Health”, without jeopardizing my current coverage– they can’t grant me a special extension to refile while they examine their clear error in denying me the subsidy the law entitles me to now.  I snarled a bit then preserved my right to appeal the removal of my subsidy.

My navigator heard that I am unable to refrain from snarling at the NYS rep Clint Eastwood-like but at length, whenever my low threshold for frustration is exceeded.  Now, no doubt, she understands that this Patient Protection Act shit has driven me a bit crazy.

The first time I exploded was when they rejected my appeal request because my scanned tax return with my signature did not have a handwritten date next to my signature, only a typed one by the paid preparer, a filing date verified by the official IRS tax transcript which was sent with it…

My navigator, a lawyer who works for a busy nonprofit assisting some of the thousands fucked by the Patient Protection Act, looked over a previous draft of my letter to the AG.  She emailed that I needed to focus on what I was really asking the AG to do– in the mode of “question asked”.  At law, you can’t complain without requesting specific relief within the power of the person you are petitioning to grant — well you can, but it won’t get you anything. 

It’s like that dilemma described in “Standing on a Phantom Leg” — part of my unconscious grapple with this very issue of being fucked without a remedy at law.  The complaint can be irresistibly well-drawn, but for legal purposes, it has to state a “cause of action” and request specific relief the court can provide.  The letter as written, and posted the other day as Son of Letter, in addition to being bloated and senselessly recursive, really doesn’t state exactly what I am asking the AG to do.

Reading a skillful litigator friend’s critique I realized the most recent draft of the letter was a long foul ball.   If I wrote it to the chief of the legislature, and my congress person, and everyone else in the New York State legislature, maybe a reasonable letter– since they are the ones to write the laws.  But all the AG can do is enforce existing laws.  I have to convince him that NYS insurance companies routinely commit widespread fraud against mandated low-income health insurance buyers utterly unprotected by New York State law, in spite of the fig leaf of administrative supervision by the Department of Financial Services.

Will it persuade the AG to rush off for a news conference (he’s a progressive and a publicity hound)?  That is the only question to be asked of the letter.  Written well but not hitting the mark?  Who cares? I have no time for that kind of writing.  I need this letter to be a clean base hit if I have any hope of it spurring the AG to action.

THIS JUST IN:

The New York State Attorney General has the power to, and does, propose legislation.   Yee fucking hah!  Back to the drafting table.

Son of To Whom It May Go Fuck Yourself

The Honorable Eric Schneiderman
Attorney General of New York
The Capitol
Albany, NY 12224-0341

Dear Mr. Attorney General,

I am writing to alert you to a massive consumer protection failure in New York State and to seek your help in correcting it. There is currently no state agency meaningfully overseeing the practices of private corporations providing health care insurance in the state of New York.   This letter lays out the current non-functional administrative apparatus, such as it is.  

I urge your office to launch an investigation into this administrative vacuum.   Patients faced with denial of needed health care services have no government forum in which corporate abuses, oversights and fraud can be remedied.   An investigative report would recommend legislation to redress the literally life-threatening menace of corporate denials of health care without any recourse under the law.  At minimum we need something like a State Ombudsman’s office to oversee health insurance in our state.

As our new president forcefully carries out his announced intention to dismantle the apparatus of government regulation, the need for state oversight of health industry corporations in New York State has become urgent. The promised replacement for the Patient Protection and Affordable Care Act (“PPACA”), whatever it might be, won’t eliminate the need for protection of vulnerable older and low-income healthcare consumers.   It is unlikely that the need for these protections will become less pronounced under a completely deregulated health insurance system.

The administrative ‘remedies’ that currently exist in New York State allow no timely or meaningful process to resolve adverse healthcare-related decisions. That there is no state agency empowered to supervise this crucial sector of our state’s welfare is a terrible oversight.

I’ve admired the courageous and proactive steps your office has taken against the powerful perpetrators of various frauds and urge you to consider this letter in the context of systemic healthcare-related fraud against a large class of vulnerable low-income and senior citizens of New York State.

Uncertainty about health care, lack of information about high surprise costs and the denial of prescribed medical services without explanation are all stressful. They negatively affect the health and quality of life of those mandated to purchase their health insurance plans in New York State.   As detailed below, health insurance buyers in our state are denied any state protection against the practices of private health insurance companies, even when the denial of necessary service appears to be fraudulent.    

This consumer protection emergency transcends the current health care scheme under the PPACA.   The president’s threatened repeal of the PPACA makes it all the more essential for New York State to regulate private health insurance companies.  

In googling your mailing address to mail this letter I came across the New York State Health Care Bureau, under services at the bottom of your office’s home page. That bureau informed me they can help me resolve a billing dispute with a provider or insurance company. The citizens of New York State sorely need a regulatory apparatus that can make expedited, binding determinations on when insurance companies cross the line into actual fraud against their mandated customers.  

 Of course, the creation of a regulatory agency is a matter for the legislature. A fraud investigation by your office into practices such as the ones described below would highlight the need for state regulation; a report would give momentum to legislation to create a bureau where life and death health decisions could be expeditiously heard and resolved.  

As stated, defrauded health insurance consumers (patients) in New York State have no forum where complaints can be resolved, outside of the New York State Department of Financial Services, which, it turns out, does not hear such complaints.

The fraud investigator I spoke to there could not find a word other than ‘fraud’ to describe the facts I set forth, but urged me to call the NY State Department of Financial Services Consumer Services Hotline. He assured me that they were the specialists in the area of health insurance. The recorded menu at the hotline, which I recognized from my first call many hours earlier, offers no option for resolving issues with insurance companies of any kind.  

On my original call to the Department of Financial Services, a long wait to speak to a representative yielded the number of the proper federal agency to contact.   Calls to the U.S Department of Health and Human Services are robotically routed to a NY State number that is, sadly, the office of Temporary and Disability Assistance, where a helpful party connects you to a fraud hotline, which turns out to be at the office of the Medicaid Inspector General, where the office of legal affairs is also sympathetic, but unable to help, and so forth.

As for the PPACA, I understand that it was drafted by Liz Fowler, a career health industry insider who went on to a senior executive position with Johnson & Johnson immediately after her work on the PPACA was done. I‘ve witnessed the many attempts to repeal the law and thwart its implementation, rather than fix any of its original flaws, as other complicated laws affecting millions are tweaked and improved over time. Even so, the lack of any provision for oversight of corporations participating in the PPACA by New York State is grotesque. To a sixty year-old cardiac patient unable to see a cardiologist now for many months, the lack of oversight may also be deadly.

Although the situation I’m complaining of is personal and extremely aggravating, it is sadly typical.   I’ve commiserated with many others who suffer under similar insurance coverage.  Erroneous bills are a common, if relatively innocuous, theme.

I receive bills that there is no way to resolve, most recently an invoice for $1,324 for a fully covered sonogram I had in August. The x-ray and kidney sonogram I also had that day were fully covered, the sonogram of another body part was not.   The billing issue was resolved with the insurance company (Anthem/Empire Blue Cross) and the provider to a zero balance in October. Two months later, the full bill for $1,342 was sent to me again in a Third Notice.  

Nobody at Empire could give me the reason the provider had sent that bill, although the representative, who checked my account and called the provider again, informed me that, this time, it was my responsibility to pay it in full.   She offered to send a consumer handbook for my plan that would fully explain the reason, which she claimed was clearly set forth there, though she could not state it.

There is nobody in New York State to adjudicate something as small as a billing dispute, let alone fraud, outside of a judge on some court one must file an actual lawsuit to appear before, assuming one could find a cause of action to get in the door of the courthouse.

Empire recently sent me an email warning of termination of my insurance for non-payment of December’s premium. This warning arrived two weeks after their email confirmation of my payment for December and January.

More ominously, a patient can be denied medical service without explanation (site-specific provider NPI numbers and proper CPT pre-authorization codes notwithstanding), and there is nobody in New York State you can appeal to, except to the insurance company itself.   Empire Blue Cross “Health Plus” recently sent me to two providers for needed medical services, a cardiologist and a physical therapy facility.  Neither provided me with any service. 

I received the site-specific NPI number for the cardiologist, scanned and emailed the back and front of my insurance card, got pre-approval from his office. The consultation was halted ten minutes in and I was informed that my insurance would not cover the visit.   When I arrived at the ‘physical therapy facility’ Empire had referred me to, it was a nursing home.  The director told me the facility offers PT, but only to residents.

The circuit of government agencies I have contacted in vain came full circle with the “consumer help line” the NYS Department of Financial Services Fraud Unit investigator had me call, which I immediately recognized as the very first number I’d called.   Here is a summary of that cul du sac:

NYS Department of Financial Services referred me initially to the US Dept of Health and Human Services which, supposedly, connected me to NYS Health and Human Services, although to an incorrect branch of that agency, the pertinent branch apparently having been merged into the NYS Department of Financial Services which took over all functions of the former NYS Insurance Department as well as oversight of banking and several other discrete and seemingly unrelated areas.  

The NYS Department of Financial Services, one learns, has sole responsibility for oversight of health insurance companies, as well as all fraud investigations related to consumer fraud against insurance companies, and complaints about the practices of banks and brokers.   Everything but, according to a fraud investigator for the Department of Financial Services, investigations of colorable fraud committed by insurance companies against mandated health-care “consumers” in New York State.

My political and legal conclusions are beside the point. Whatever the reasons, the fact remains that in New York State in 2017, even under the PPACA, citizens whose health is menaced by private insurance company denials are denied any legal process to have these vexing, sometimes life-threatening situations resolved.   

Outside of a possible Article 78 (which government agency would you sue for relief, the Department of Financial Services? The New York State of Health Marketplace cannot be sued, even over their own clear error, until exhausting their slow and inadequate ‘administrative remedies’) or a class action under a private attorney general or qui tam statute, what is a patient trying to get an appointment to see a cardiologist since August to do under the PPACA in New York State?   At minimum an ombudsperson, or a few hundred of them, would be a good start.

I’ve followed your career from the start and have admired your principled engagement in the fight against injustice.   To have a legal right that cannot be enforced is to have no legal right.   The mere existence of an ‘administrative process’ (four to six month wait for an appeal of a clearly erroneous adverse NYSOH determination) does not mean there is anything like due process. Widespread injustice is accounted by some as a kind of ‘externality’, a cost of private industry doing business. The lack of legal recourse for denial of purchased health care must not be allowed to stand in New York State.

I have attached the specific grievances I was until the other day unable to submit directly to Anthem/Empire.   I have forwarded them to the organization indicated in Anthem/Empire’s internal directive. I have since learned from an attorney at that non-profit that they do not play this role in the complaint process. She provided me with an online version of Empire’s Handbook, I quickly found the mailing address for complaints on page 15.

I will be glad to do what I can to help your office take steps towards sorely needed due process for denial of health care for some of the State’s most vulnerable citizens.  If needed, I can assist in researching and drafting the report. I am open to being a plaintiff in any lawsuit the State might want to bring and to testifying in any proceeding, in any forum.

I look forward to hearing from your office and stand ready to give any other details or assistance your office might require.

 

Yours sincerely,

 

 

 

 

The Constant Sharp-toothed sucking

Frank Zappa had a song called “The Torture Never Stops”, which is about right. Like pugnacious people looking for a reason to punch someone, it’s one of those things that hums along in the background of our enraged, maddening world.  Here’s a seemingly random one, crosswise in the old throat, that I will try to briefly dislodge.  

That’s one of the beauty parts of writing.  Describe it well and experience a moment of relief.  Why am I foaming at the mouth, you ask?  Let me wipe away the foam, like Mr. Hitler delivering a coherent, if amoral, description of effective propaganda in a book otherwise composed of rabid dog spittle, and give myself that momentary illusion of relief.  

The current figurehead of our Deep State, an entitled, irascible and seemingly unhinged reality TV big shot, has promised, among other things, to abolish and replace Obamacare.   That he is the man to provide America with a health care scheme like the one citizens of every other wealthy nation depend on is as ridiculous an idea as his modern day Great Wall of China proposed for our long southern border.  I have critiqued the corporation-friendly, cynically-named Patient Protection and Affordable Care Act at length.  You can click on the Obamacare link stage left (to the right for you pogues) to read the disheartening details.  I am no friend of Obama, a probably good man with a record of accomplishments as shameful as Bill Clinton’s.  Depleted uranium and cluster bombs dropped in Syria?  Not done by Mr. Trump, that was the handiwork of my man the Nobel Peace Prize laureate.  

Anyway, in the last phase of Mr. Obama’s second term, New York State came up with a pay-as-you-go Medicaid plan for New Yorkers living slightly above the poverty line.  It’s called the Essential Plan.  The name turns out to be apt.  You can essentially get the health care you can force someone to provide under the plan.  Based on my income I qualified for this no-frills plan.  In fact, I was forced to enroll, or have no health insurance and pay a fine as a scofflaw come tax time.  

My experience with this “Essential” plan was literally sickening.  I wound up so sickened that my visit to the ER resulted in my being hospitalized for cardiac tests.  Follow-up care was deemed unnecessary, an undue burden, no doubt, on the corporation to which I paid my low monthly premium.  

When I enrolled for health insurance in 2017 I was determined to pay more and get a plan that could provide me with some measure of actual health care.  My subsidy level, and choice of plans, would be determined by my projected 2017 income.  It had to be above a certain level, to allow me to choose anything but the Essential Plan.  My actual 2016 income would have doomed me to the Essential Plan.  Luckily for me I was not asked my actual 2016 income, I was asked to project my 2017 income.  

After hours on the phone I learned what was not available anywhere on the internet– what the income threshold to choose a health plan was, somewhere around $29,000.  Nobody could tell me if this was gross or net income, so I declared my 2017 income to be a robust $32,000, to leave myself a margin for error.  

I instantly received a Notice of Disenrollment.  What I mean is that, this shit popped up on my screen within seconds of clicking in that income number.  I got a document emailed to me at the same time, helpfully labeled Template 09, like all the others, which informed that I was no longer qualified for the Essential Plan.  Good news, I naively thought.  

I will spare you a hundred details and tell you that my Navigator (the website and marketplace are so opaque it literally requires a navigator to help you get around) informed me that my income level qualified me for a subsidy of about half the monthly premium.  Meaning, with the subsidy I’d pay an affordable $230 a month for “Silver level” Obamacare with only a $1,200 out of pocket deductible.   Meaning that’s what I should be paying, under the law.  Except I’d had another notice telling me, erroneously, that I was not entitled to any subsidy.  Fair enough, we have already had vivid illustrations of what contemptible morons the administrators of the complicated and opaque program are.  

It will take about six months to have my appeal heard, my Navigator (also an attorney at a New York non-profit mandated to help consumers) informs me.  In the meantime I will pay $453 a month and have a $2,000 deductible.  Although, once they correct their mistake and reinstate my subsidy I will get a tax refund, some time in the second half of 2018, for the overpayment in 2017.  All I need to do to get an appeal of their clearly mistaken determination is to submit a letter, my 2015 tax return (the last one filed) and a Tax Transcript from the IRS.  

What the fuck is a Tax Transcript, you ask?  No fucking idea.  Click this  shit to learn all about it:  https://www.irs.gov/individuals/get-transcript.

OK, easy enough.  The IRS will send you an electronic one, chop chop.  All you need to do is create a log-in and request one.  They assure you it’s quick to create a log-in, only about 15 minutes.  Easy.  Except that each of the four times I have tried so far, over the course of more than an hour over two days, punctuated with Tourretic outbursts that have terrified, and horrified, Sekhnet, they log me out, sometimes because their system malfunctions, other times informing me it’s done for my own protection, before I can complete the process.  There is no 800 number where you can speak to a human being for assistance.  

So, I can just relax for Presidents’ Day Weekend, since there is nothing to be done at the moment.  Two days in a row, unable to complete this easy log-in business.  No reason to get excited.  Just keep loaning this giant insurance company $230 a month, since I’ll, theoretically, get it back a year and a half from now anyway.  Assuming this Orange Winner does not actually make good on abolishing the whole plan and replacing it with something terrific.  

I feel much better now, thanks, I really do.

Obamacare dramatically reduces preventable American DEATHS!

Before the puckishly named Patient Protection and Affordable Care Act became law, 45,000 was generally accepted as the number of Americans who died every year of conditions that would have been curable, had they not been diagnosed too late in an Emergency Room.  Thanks to Mr. Obama’s inspired and innovative health care scheme, that number may now be as low as 25,000 dead Americans a year for lack of health insurance.  Almost half of the 60,000,000 previously uninsured Americans are now covered under the PPACA.  An achievement anybody would be proud of, any way you slice it.   Shoot, 7,300 American veterans take their own lives every year in this country, for Christsake, as the president informed us on Veteran’s Day (20 American veterans take their own lives every day).

Admittedly, the PPACA health insurance system is still not perfect, even in states that adopted it early and eagerly, like New York State.  If you want a wee taste of the PPACA in action, and a very dry little chuckle, read the helpful paragraphs below and click on the link to see the list of providers.  This is from the New York “State of Health” “Marketplace” website.  It is for sure worth a quick click:

On this page, you will see the plans that are available for you to purchase. You can search plans by different criteria such as how much you will pay each month (monthly premium), the category (metal) of the plan you want, and/or the health insurance carrier you prefer. You can search for plans based on their quality ratings.

You can also see the plans that your doctor accepts, or plans that include hospitals or other facilities that you use. Click here to search for doctors and facilities. By clicking on the link, you will be re-directed to the NYS Provider & Health Plan Look-up website. However, this does not guarantee that your doctor accepts the plan. In addition to using the search function, call your doctors hospitals, or other facilities to see what plan they accept.

You can apply for an affordability hardship exemption if you think you cannot afford to purchase health insurance due to your projected income in the coming year. Click on Apply for an Exemption for next steps.

Disclaimer: CMS is conducting additional consumer testing regarding the public display of quality rating information.

Not to be rude, but who the fuck is CMS and when are they going to get their collective head out of their collective ass?