Choosing to not have medical insurance
He covered the healthcare industry for much of his career and realizes the importance of a safety net. But after weighing the risks and benefits, he is going it alone.
Insurance against the unforeseeable, after all, is what makes middle-class existence possible. Yet, as the country debates the merits of reforming the rules around insurance markets, it's worth pondering what value health insurance really adds for individuals under the current system.
I have no insurance partly by accident and partly by intent. I'm not freaking out, though. Should I be? I'll tell you what I know. Then you decide.
A little more than two years ago, I quit my job. It was, on the face of it, a good job, with a high salary, professional prestige and a luxury health-insurance policy. But I was miserable -- so unhappy, in fact, that I started to worry about myself.
I had stopped sleeping through the night. After one particularly grueling 14-hour day, a blood vessel in my nose burst and I had to lie on the floor in the lobby of an office tower while security guards debated calling an ambulance. Without being aware of it, I lost 10 pounds over five months.
What was this fearsome job? Writing about health insurance for a news organization. I interviewed top executives at the nation's mega-managed-care companies. I attended investor conferences, covered earnings reports, wrote about clinical trials, explained Medicare benefits. I learned to love the delectable insurance lingo -- medical-loss ratios, adverse selection, moral hazard, the underwriting cycle -- that make normal people feel as if they're stirring concrete with their eyelashes.
But the deadline stress was killing me, and I decided not to die before my time. I signed up for the 18-month COBRA extension and began paying $447.12 a month out of my savings for health insurance. I assumed I would find a job, with new insurance coverage, soon enough. I didn't anticipate the economic crisis or the collapse of the journalism profession.
When the COBRA coverage was about to expire and I still didn't have a job, I considered the insurance problem from two perspectives: my health status and history -- and what insurance actually buys. The answer I came up with surprised me.
Healthy lifestyle
I've always been a naturally healthy person. I eat right and get plenty of sleep. All my life I've avoided unhealthy behaviors like crack cocaine and yoga. My parents are in their 80s and in great shape. There's no cancer or heart disease in the family history. My Scottish grandparents lived to be 87 and 91.
Like a lot of guys who were not especially athletic in their youth, when I hit my 40s I decided to become a stud. I taught myself to swim and started lifting weights. I sold my car 10 years ago and started taking public transit. In warm weather, I ride my bike everyplace I need to go. I've never been overweight. I'm fit, trim, well-proportioned. My body mass index hovers around 24.7. (At 25, you are borderline "overweight," but people with strong bones and lots of muscle mass like me tend to tilt toward overweight in that metric.)
If I were going to develop a chronic disease, I'd have it by now. My blood glucose tends toward the low end, so I'm not going to become diabetic. I have some lower back pain and stiffness from a herniated disk 15 years ago, but I manage it with strengthening exercises and stretches. Knee or joint surgery? I don't like to run. Cancer? I never smoked. I had a colonoscopy at 51 and saw for myself on the video monitor that I'm clean as a whistle down there. I did, however, have early signs of a precancerous condition a few years ago.
I had some tests, and doctors believe it won't turn into anything serious. We are watching the situation. (According to insurance brokers I consulted, however, that condition could be enough to exclude me from qualifying for an individual policy.)
As to heart and vascular risk,I have always had low blood pressure and pretty good, though not ideal, cholesterol. I got my last blood work-up numbers from my doctor and plugged them into the heart attack risk calculator on the website of the National Heart Lung and Blood Institute. My risk score is 5%. Five of 100 people with this level of risk will have a heart attack in the next 10 years. That sounds acceptable.
So what does a guy like me need with health insurance? I'm the best risk in town, I thought to myself. Why shouldn't I self-insure? In other words, why couldn't I accept full responsibility for my own health expenses?
That's what big companies do. They hire a health insurer to "rent" a network of doctors and hospitals; they also pay the bills for their employees and encourage healthy habits. But the actual medical risk is held by the employers themselves. Companies save a lot of money that way. Risk management is where insurance companies make their big profits.
And so I decided: Why shouldn't I create my own network and find providers who would give me a discount for paying cash? I know how to be a savvy medical consumer. Twelve years ago, I needed a gum graft, and was told my insurance wouldn't cover it. I called oral surgeons until I found one willing to give me a firm price for the procedure. Most doctors don't like to cite a price in advance, but as the U.S. health system moves toward asking patients to pay a greater share of the bill, doctors are going to have to become more responsive to their patients' cost sensitivities.
About a year ago, when I was looking at the end of my COBRA policy in a few months, I talked to the business manager at my regular physician's office about my options. He said the office offers a standard discount to people without insurance, ranging from 20% to 40%, depending on the service or procedures performed. Diagnostic tests and X-rays are another matter, he said. He advised me to check in advance what sorts of discounts might be available. For hospitalizations, major medical centers in Chicago, where I live, are giving pre-arranged discounts, ranging from 15% to 58%, to patients who don't have insurance.
A month ago, I went to the doctor for a checkup. My "intermediate" visit, billed at $100, was discounted to $65, and some routine cholesterol tests, billed at $195, cost me $110. I wrote two checks on the spot. There was no paperwork, no correspondence, no phone calls, no arguing about deductibles or co-pays, for me or for the doctor's office. And the doctor got his money immediately.
The truth is, I still have money in the bank and can afford to pay most bills myself. A disaster costing more than $50,000 would be a problem, but short of that, I could handle it.
A few years ago I worked for a large consulting firm. The head of the healthcare practice used to argue that the U.S. will get a grip on its exploding healthcare costs only if consumers have "more skin in the game," as he put it. Regular people have to face the real costs of their medical options, instead of having them hidden behind employer-sponsored insurance or Medicare, and choose more wisely. I'm prepared to pay those costs, within reason, and consume medical care more sparingly.
Most health insurance payments to providers are for routine services that, strictly speaking, are not insurable events. The real purpose of insurance is to protect you against sudden, unexpected, unaffordable events, for instance, a heart attack or cancer diagnosis. Yet that's not how most of us use our health insurance these days. We use it to pay regular, predictable expenses such as office visits, diagnostic tests, dental cleanings and eye exams.
Giving up conventional insurance that covers all these routine expenses, however, still leaves people exposed to the risk of unanticipated catastrophe, the expense of which can sometimes force people into bankruptcy.
For me, the main medical risk is being hit by a bus or cab, or falling off my bike. But even if I bought a policy, there are no guarantees that the insurance company would pay, that it wouldn't try to weasel out of the obligation.
Avoiding payment
That brings me to the single most terrifying aspect of health insurance in America today: rescissions. This newspaper has published a drumbeat of horror stories -- notably in a 2006 article and many since -- about Californians who had purchased health insurance and paid premiums in good faith, only to find their policies revoked once they made expensive claims for major illnesses, such as cancer, or procedures, such as heart surgeries. This portrait of the health insurance industry has been horrific.
Around the same time the articles began, I learned that my music teacher had been hospitalized for two weeks in a coma that he had barely survived. Like many creative types, he was self-employed, with an individual policy. His insurer reneged on the bill, asserting that the coma was the result of a preexisting condition. The hospital is now pursuing my teacher for a six-figure medical bill. It could cost him his house. It's one thing when it happens to anonymous people a thousand miles away, another when it happens to somebody you know.
On July 21, the Chicago Tribune splashed across the front page the story of a man who got preauthorization for an expensive back operation. Yet after the $148,000 procedure was done, UnitedHealthcare, his employer's insurer, refused to pay -- even though it had already authorized the surgery. After the patient wrote to the Tribune's "What's Your Problem" columnist, and after the newspaper made inquiries with UnitedHealthcare, the decision was reversed and the insurer paid the bill.
The industry's continued use of rescissions to evade bills that companies don't wish to honor eviscerates the value of health insurance. To a person like me, who is on the margin, rescissions are the deciding factor between purchasing and not purchasing insurance.
As I indicated earlier, I believe in insurance. Honestly, it is foolhardy for a middle-class person to go without it. Yet as long as the insurers can use medical underwriting to exclude poor risks and redline preexisting conditions -- sometimes retroactively -- insurance isn't worth what we're being asked to pay.
I'm looking forward to the day when all of us will qualify for good medical insurance at reasonable prices, with a firm regulatory hand behind it. If we all have to pay into the system in order to make health reform work, so be it. I'll gladly pay if I'm assured of getting the services I contracted for.
In October, I'll hit 12 months without insurance, and I will have saved about $6,000 that otherwise would have padded the profits of the insurance companies.
Eventually, I will have some serious medical expenses, and I'll use these savings to pay them. Between now and then, I'm going to wear my bike helmet and stay off the rollerblades.
Moore is a freelance writer in Chicago and the co-founder of the Assn. of Health Care Journalists.
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