Phew! This is the collective cry of the insured. The uninsured face physicians who refuse to see them, long waits at neighborhood clinics, dunning letters from emergency rooms, and bills for short-stay hospitalizations that are twice their annual income. American medicine offers a wondrous world of treatments. But the uninsured cannot easily enter. The insured, though, have an “open sesame” key. Phew!
But that “phew” may be premature. Laminated insurance cards give most holders only limited access to this wondrous world.
As an exercise, call up your insurer, and, after going through the Pakistan-based call center, ask about some of the more expensive treatments. Will your child get plastic surgery for a cleft palate? More than rarely, parents of children born with serious facial deformities learn the good news and the bad news at the same time: surgeons can ameliorate the disorder, but the insurer won’t pay, considering it “cosmetic.”
Will the insurer pay for psychiatric treatment? For psychiatric hospitalization? How many days?
What about cardiac rehabilitation?
Indeed, what about physical, occupational, and speech rehabilitation? Million of people who need these treatments learn that their insurer won’t pick up very much of the tab. Or maybe their insurer will say yes to any treatment – but imposes a “cap” that makes the point moot.
Admittedly, by now most Americans recognize that their policy may have shortcomings; but they cling to the happy hope that it covers the “basics,” whatever that is.
So a recent Journal of the American Medical Association article, cited in The New York Times Aug. 7 edition, comes as a shock: for many insurers, the “basics” don’t include vaccinations.
The government has poured millions of dollars into the development of new vaccines. Investors have poured in their capital. We have vaccines for an array of illnesses, including measles, chickenpox, hepatitis A, tetanus, whooping cough, pneumonia, rotavirus.
The benefits seem obvious. Since prevention is always better than treatment, physicians urge these vaccines on their patients. Furthermore, since some of these diseases are contagious, public health officials join the “get-vaccinated” chorus.
Some insurers, though, are less interested in the public’s health than in their own coffers. Researchers found what seems to be an anomaly: insured children who are not vaccinated.
The plight of enrollees with less-than-comprehensive insurance is like a combination punch in boxing. The left jab comes when the insurer says “no.” The right cross comes when the public clinics say “no.”
All states offer free vaccinations to people without insurance. Again, this is a public health concern. But many states, hamstrung by limited budgets, restrict those vaccinations to people who are uninsured or covered by Medicaid.
The people with some insurance are left in a bind. Their insurer says “no.” And so does their state. Too many parents have discovered that their insurance card not only doesn’t get them the basics – it keeps them from going to the public sector for the basics.
Of course, parents could pick up the tab, $900 on average for boys and $1,200 for girls. But many do not – deferring the vaccinations, perhaps, until they get better coverage.
The solutions are not simple. State legislatives can – and do – mandate that private insurers cover vaccinations; but millions of employees are covered under self-insured plans. Those plans escape the umbrella of state mandates.
States could provide all vaccinations free of charge, regardless of patients’ insurance status. That would solve enrollees’ dilemma. That would also raise taxes, as states scrambled to come up with the revenue for vastly expanded coverage. Pragmatically, insurers would probably drop all coverage for vaccinations if states made the service free and universal.
Presidential candidates who promise to bring the 47 million people without insurance into private-sector plans are hailing the efficiency of the private sector. But while those plans may be efficient at making profits, they are not so zealous at making their enrollees healthy. •
Joan Retsinas is the managing editor of Medicine & Health/ Rhode Island, a monthly journal of the Rhode Island Medical Society.
