Pt 3: "It wasn't me, Deborah; it was the President"

Here’s the bottom line (details in earlier posts): Before health care reform passed, I was paying $220 a month for health insurance and getting nothing for it. Specifically:

• I paid out-of-pocket to get my teeth cleaned, even though I had been paying for dental, because of an insurance company mistake!

• I paid out-of-pocket for my annual exam, because my insurance didn’t cover any gynecologists in the District.

• And now I was paying out-of-pocket for my prescription drugs because I had hit the $1,500 prescription drug maximum?

• I had no recourse. In this world, Goliath shows up with a nuclear missile. You fight, you lose. The End.

What exactly was I paying $220 a month for?

(Let me add that I have always paid out of pocket for my therapist, whom I have been seeing for years. She is an out-of-network provider. Years ago, at my old job, and on COBRA, I got partially reimbursed. Under my “open enrollment plan,” which I joined in 2005, I got nothing.)

My feeling had always been that I had to have some kind of insurance in case I got hit by a bus, but this was getting worse and worse. Besides, I was starting to doubt if getting hit by a bus would even BE covered. (Don’t even want to think about that fight.)

I had no idea what I was going to do.

See, I had two essential problems: 1) I had a pre-existing condition, depression, and 2) I was self-insured. Pre-health-care-reform, HIPAA required insurance companies to offer me some coverage, but they could charge whatever they wanted. Care First had the best plan available to me. A comparable plan from Kaiser was $574 a month, so I actually felt pretty lucky at first.

I decided to stay on the phone until I got some answers. Maybe I could upgrade my plan – almost anything would be an improvement at this point.

In a phone-bank scenario I keep calling until I get the same story twice. Everybody says something different. So I had called a couple of times when I finally spoke to a lady who – very apologetically – explained “the $1,500 prescription drug ceiling.” The insurance company pays up to $1,500 for prescriptions per year. Once that’s maxed out, the subscriber has to pay out-of-pocket.

“But I’m paying $220 a month,” I said to her.

She told me to get a generic.

“But I’m paying $220 a month,” I repeated. “I already have to pay out of pocket to get my teeth cleaned and get my annual exam. I’ve always paid out of pocket for my therapist, that’s never been covered. And now, I have to pay out-of-pocket for prescription drugs, too? What exactly does my $220 a month pay for?”

She felt for me, she really did.

“Lisa,” I said (her name was Lisa), “This is the kind of stuff pushes folk over the edge.”

She laughed and said, “You need to quit the plan and re-enroll. The health care law gets rid of the $1,500 maximum, but they don’t have to apply it to existing subscribers, like people with the old plan."

She told me what to do – fax a hand-written request to quit the open-enrollment plan, along with an application to the open-enrollment plan [sic], a copy of my ID, and my original insurance card.

It was like finding out how to get into Skull and Bones. For some reason I lowered my voice.

"Lisa," I said. "Lisa, why doesn't anybody else at the phone bank know this information?"

She said, "It's really new. Not everybody knows about it yet." After a pause, she added, "It takes a while.”

Now that rang true. It sounded like a dream, and I had long ago learned not to "hope" for anything when it came to health insurance. It was a fact of life that health insurance sucked, and that I would be victimized.

But Lisa sounded like she believed what she was saying, and at this point I had nothing to lose. So I did what she said, and went back to contemplating a prescription run to Tijiuana.

A few weeks later I got my new health care "package" in the mail. It was a big envelope with a manual and a letter that said, "Congratulations!"

I was in the same plan -- at least, it had the same name -- but when I sat down with the manual and looked for the $1,500 prescription drug maximum, it wasn’t there. Flipping through the manual, I found a section on dental. Apparently, my plan now included dental (it used to be an additional $10 a month, and an additional bureaucratic nightmare).

Later, I got another letter saying that “due to federal regulatory reforms,” they were now required to offer something for out-of-network providers if you had a referral from your PCP. They explained the procedure. I damn near fell out of my chair.

I still refused to hope. Because you don’t really know what the deal is until you’re at the pharmacy cash register.

For the past 2 months I had paid $430 for one of my prescriptions -- $430 for 30 pills (see parts 1 and 2). This was after paying my $220 monthly premium. And paying for therapy.

I read that manual cover-to-cover. Then I called in the refill and went to the pharmacy, where my $430 prescription was infamous. I’ve been going to this pharmacy for 10 years, so they know me. The pharmacy tech on duty, Deborah, looked sorry for me as I walked up.

I closed my eyes and crossed my fingers as Deborah retrieved my prescription and looked at the blue label. She usually flinched. This time, her eyes got wide.

“That’s $60,” she said.

“They covered it?” I said.

“Yeah, they sure did!” she cried.

“Now that’s what I’m talking about!” I yelled. “Oh my God!”

Deborah smiled. “I’m glad you got it worked out, Ms. Phillips.”

“It wasn’t me, Deborah,” I said. “It was the president.”

And I didn't even vote.

Because my president led this health care reform effort, I am now paying $186 a month and

• There is no $1,500 prescription drug maximum. It ain't allowed. My $430 bottle of pills costs me $60 a month, and I am overjoyed.
• Dental is included, which means it’s understood that I have dental – everybody has dental!
• For certain specialists (like gynecologist and psychiatrists), even if they’re out of network, Care First has to cover between 60 – 75% with a referral from my PCP.
• This was the case for several kinds of specialist, but not for everything. I went to my PCP, got a referral, and filed a claim for my therapy sessions. I got reimbursed for 3 of them – and I will, each year.

That may not sound good to you, but I was ready to take out a full-page ad in the New York Times. After all these years, I was getting something. I really wasn’t asking for much. I am paying $186 and getting something. That’s all I wanted.

It brings tears to my eyes when I think about it. It was so horrible feeling violated, and hopeless, and to have no choice, no help, from anybody. To be at the mercy of an insurance company – a largely incompetent insurance company – was horrible.

I don’t know the ins and outs of health care reform, but I do know that Care First didn’t make these changes out of the goodness of their hearts. They’re not even sending letters to inform existing subscribers about it (unless they happen to talk to Lisa, I guess).

But for those of us who were in a crisis, the federal government came through. I had no recourse, and it was wrong. What was happening to me was wrong. Nobody had to do anything. But President Obama made sure Congress did something. And he’s catching hell for it.

I defy anyone to lay out for me, in black-and-white numbers, how health care reform has harmed them. Because I was in a shitty situation that has gotten sooo much better – and they’re still making changes. They do send a letter periodically explaining some change or update brought about by “federal regulations.”

Instead of letters telling me my premium is going up, I am now getting letters telling me about improvements.

I pray that the health care reform law survives. Just in case, I’m going to start saving now.

I'll probably start voting again, too.