An illustration of the problem with UHC

[Bronzeage]

I don't know where you got that idea. I typed in "How to appeal medicare coverage denial?" and found this website:

File an appeal

When someone calls a private company to account for denied coverage, it's called a civil suit. The government is infinitely more callable than a private insurance company.

If you have your health insurance from your employer and they are a large company, say more than 50 to 100 employees then most likely your company is self-insured. Who ever you think that your health care insurance company is, Wellpoint, Blue Cross-Blue Shield, Atena, etc. they aren't. Your company hires them administer the health plan but they don't have any financial interest in your care. For a fee of say 5% they collect all of the bills for the medical care of all of the employees for your company, add them up and add 5% to the total and send it to your company. When they get the payment from your company then then they pay the doctors, druggist and hospitals.

If the insurance company denies coverage just go to your boss and complain. If your company is willing to cover it then the insurance will, after all your company is paying for it. The insurance company doesn't care. In fact they will earn slightly more money, the 5% of the cost of the previously denied item.

I've seen a few situations where Employer provided coverage declined to cover a specific procedure.These were medium sized companies and had an actual group policy with the provider. The only real choice available to the employee was to sue in civil court.

 

[krypton iodine sulfur]

(The doc I learned this from had an example: A M->F transsexual was denied coverage.)

As mentioned by others, it's not really a universal health care issue. As a transwoman just starting transition in a single-payer health care system, I am well covered. Not only am I covered as a working person who pays taxes and health care premiums, but someone who is impoverished in my province is entitled to the exact same coverage. And not only is this a matter of my medical coverage, but in recognizing the medical necessity of the transitioning process, the government would have been hypocritical not to also recognize other important legal issues which needed to be addressed for trans people.

Am I at the mercy of the government regarding my treatment now? Yes and no. The decision to cover medical transition is not whimsical. It's informed by medical opinion and political philosophy which aren't that easy to reverse at this point in time (and I would have legal recourse). It took a long time to advance to our current level of progress on this issue, but a lot of that has to do with the fact that being [openly] transgender and requiring medical treatment is quite rare, and not receiving treatment is not directly harmful to one's physical health. Would it really have been much faster with a private insurance scheme? I'm hesitant to believe it would have made a significant difference.

Can the goverment be successfully petitioned if it isn't meeting our expectations? Yes.

Last June, [Nova Scotia] did a quick about-face, backtracking on its initial decision not to provide funding for sex reassignment surgery.

In justifying the province's decision not to pay for the procedure, then-Health Minister David Wilson cited a lack of high-quality research about the effectiveness of outcomes.

One week later the government backtracked, agreeing to pay for the surgery after reportedly reviewing the medical evidence and the policies of other provinces.

http://www.cbc.ca/news/canada/nova-...rgery-funding-begins-in-nova-scotia-1.2594418

I guess my basic point here is if a universal health care system is failing to meet these sorts of needs, I don't believe it's the universal or governmental aspect which are directly causing the problem.

 

[krypton iodine sulfur]

Ah, I grabbed from the wrong article. It's not in there, but part of why the provincial government backtracked was the public backlash following their announcement not to cover SRS.

 

[ZiprHead]

I don't know where you got that idea. I typed in "How to appeal medicare coverage denial?" and found this website:

File an appeal

When someone calls a private company to account for denied coverage, it's called a civil suit. The government is infinitely more callable than a private insurance company.

If you have your health insurance from your employer and they are a large company, say more than 50 to 100 employees then most likely your company is self-insured. Who ever you think that your health care insurance company is, Wellpoint, Blue Cross-Blue Shield, Atena, etc. they aren't. Your company hires them administer the health plan but they don't have any financial interest in your care. For a fee of say 5% they collect all of the bills for the medical care of all of the employees for your company, add them up and add 5% to the total and send it to your company. When they get the payment from your company then then they pay the doctors, druggist and hospitals.

If the insurance company denies coverage just go to your boss and complain. If your company is willing to cover it then the insurance will, after all your company is paying for it. The insurance company doesn't care. In fact they will earn slightly more money, the 5% of the cost of the previously denied item.

In Michigan, you are prohibited by law from taking civil action against an employer provided insurance provider.

 

[untermensche]

No insurance company has an unlimited formulary.

There is limited funding to Medicare, mostly due to Republican hatred of the program, which really means corporate hatred of the program.

Choices have to be made.

Hormone replacement only goes so something else can be covered.

Your squabble is with the Republican party. Not UHC.

We could easily afford a better system. But lowering taxes on the most wealthy so we can create a nice oligarchy and endless war is more important to politicians of a certain stripe.

You just ass-u-me that I'm talking about something expensive. I'm not--it's $80/yr at Walmart.

Try to read.

NO formulary is unlimited.

It is not $80 to Medicare. It is millions that can be spent on something more important.

You want more money put into Medicare?

So do I. And we could easily stop our useless and counter-productive overseas terrorist campaigns and pay for it.

 

[Loren Pechtel]

A private company could be called to account for denied coverage. The government can't.

I don't know where you got that idea. I typed in "How to appeal medicare coverage denial?" and found this website:

File an appeal

When someone calls a private company to account for denied coverage, it's called a civil suit. The government is infinitely more callable than a private insurance company.

You have an appeal with private insurance, also.

And the appeal procedure you're talking about has nothing to do with the situation I'm talking about--this isn't a case of one patient being denied, but rather all patients being denied as a matter of policy. Just because the primary reason it was used has been shown invalid doesn't mean there aren't other uses.

 

[Loren Pechtel]

You just ass-u-me that I'm talking about something expensive. I'm not--it's $80/yr at Walmart.

Try to read.

NO formulary is unlimited.

It is not $80 to Medicare. It is millions that can be spent on something more important.

You want more money put into Medicare?

So do I. And we could easily stop our useless and counter-productive overseas terrorist campaigns and pay for it.

This isn't about money. This is some moron who decided that since the primary use of HRT has been shown invalid that there is no use for it.

 

[Bronzeage]

Try to read.

NO formulary is unlimited.

It is not $80 to Medicare. It is millions that can be spent on something more important.

You want more money put into Medicare?

So do I. And we could easily stop our useless and counter-productive overseas terrorist campaigns and pay for it.

This isn't about money. This is some moron who decided that since the primary use of HRT has been shown invalid that there is no use for it.

So, this moron has no medical expertise and made this decision for erroneous reasons?

 

[Toni]

This isn't about money. This is some moron who decided that since the primary use of HRT has been shown invalid that there is no use for it.

So, this moron has no medical expertise and made this decision for erroneous reasons?

Actually, there are conflicting report about the effectiveness of HRT. Probably, the use of HRT does nothing (on average) to prolong life. Individual results may vary.

 

[Toni]

Well, Loren has a point but perhaps accidentally. The trend now is that health insurance companies follow the lead of Medicare and what Medicare won't cover, pretty soon no insurance company will cover. I'm just hoping mine holds out and am not looking forward to Medicare when that time comes.

It's a real problem that insurance companies, including Medicare, make determinations about what is or is not medically appropriate. I've had my own battles with Medicare on behalf of my mother . Not fun .

Conversely, Medicare is also usually the leader in accepting new procedures before private insurance providers.

I am not sure what your point is.

 

[Loren Pechtel]

So, this moron has no medical expertise and made this decision for erroneous reasons?

Actually, there are conflicting report about the effectiveness of HRT. Probably, the use of HRT does nothing (on average) to prolong life. Individual results may vary.

As I said, the primary use has been shown invalid.

That says nothing about the women who have severe menopause symptoms. It says nothing about M->F transsexuals. Those are both medically valid uses.

 

[krypton iodine sulfur]

As I said, the primary use has been shown invalid.

That says nothing about the women who have severe menopause symptoms. It says nothing about M->F transsexuals. Those are both medically valid uses.

Those cases can be evaluated separately and covered regardless of whether a system is universal or not. What you have illustrated is, perhaps, a problem with a particular health care system, not universal health care in general. If you are only worried about one particular system, perhaps the title of the thread should more accurately reflect that as universality is not inherently the problem.

 

[ZiprHead]

Conversely, Medicare is also usually the leader in accepting new procedures before private insurance providers.

I am not sure what your point is.

It probably would have been clearer if I'd had said "new procedures and therapies". Generally, Medicare will approve of coverage for new procedures and therapies before private insurance providers will.

 

[Toni]

Actually, there are conflicting report about the effectiveness of HRT. Probably, the use of HRT does nothing (on average) to prolong life. Individual results may vary.

As I said, the primary use has been shown invalid.

That says nothing about the women who have severe menopause symptoms. It says nothing about M->F transsexuals. Those are both medically valid uses.

PRIMARY use has always been to ease menopausal symptoms. HRT works just fine for that. Other health related benefits were extras and may provide benefits to some women. It's a trade off of risk/benefit and neither the benefits or risks are universal but depend on each woman 's body, medical history, etc.

 

[untermensche]

Try to read.

NO formulary is unlimited.

It is not $80 to Medicare. It is millions that can be spent on something more important.

You want more money put into Medicare?

So do I. And we could easily stop our useless and counter-productive overseas terrorist campaigns and pay for it.

This isn't about money. This is some moron who decided that since the primary use of HRT has been shown invalid that there is no use for it.

The only reason anybody is forced to make these decisions is because the program isn't funded properly.

Again, blame the Republican Party and the private insurers who want to destroy Medicare and oppose funding it properly.

Blaming UHC in general is insanity.

 

[arkirk]

It is about money and personal prejudices of the dufus who decides to deny something that may be needed. The money issue also comes down to another dufus in another part of the system...the legislators who need the support of profit making healthcare insurers to get re-elected.

 

[Bronzeage]

Actually, there are conflicting report about the effectiveness of HRT. Probably, the use of HRT does nothing (on average) to prolong life. Individual results may vary.

As I said, the primary use has been shown invalid.

That says nothing about the women who have severe menopause symptoms. It says nothing about M->F transsexuals. Those are both medically valid uses.

Is there any potential problem with universal healthcare which does not currently exist in policies sold by corporate health insurance companies?

 

[Loren Pechtel]

As I said, the primary use has been shown invalid.

That says nothing about the women who have severe menopause symptoms. It says nothing about M->F transsexuals. Those are both medically valid uses.

PRIMARY use has always been to ease menopausal symptoms. HRT works just fine for that. Other health related benefits were extras and may provide benefits to some women. It's a trade off of risk/benefit and neither the benefits or risks are universal but depend on each woman 's body, medical history, etc.

Remember, this is Medicare--over 65s. Most women don't need it that long for dealing with menopause symptoms.

 

[Loren Pechtel]

As I said, the primary use has been shown invalid.

That says nothing about the women who have severe menopause symptoms. It says nothing about M->F transsexuals. Those are both medically valid uses.

Is there any potential problem with universal healthcare which does not currently exist in policies sold by corporate health insurance companies?

The problem is one of accountability.

 

[bilby]

Is there any potential problem with universal healthcare which does not currently exist in policies sold by corporate health insurance companies?

The problem is one of accountability.

The question was about a problem "which does not currently exist in policies sold by corporate health insurance companies".

The accountability problem most certainly occurs in both systems; Arguably it is less of a problem in government run UHC, where every patient is effectively a shareholder, and at least has a vote.