July 5, 2009, 8:23 pm

Think You Know the Answers, but the Questions Never End

Crutch WalkingWhat is this?

An illustration from “Physical Therapy for Zombies”?


The crutches are way too long and there is no banister on the stairs.

Actually, I don’t even see a second crutch.

Is the nurse is standing by or running up to rescue this guy?

If he is trying to elope, he isn’t going to get far!


Remember to send your Change of Shift submissions to me by Wednesday evening! The anniversary edition will go up this Thursday.


I figure if you are trying to understand something, begin with how it affects you. Make it personal, and it’s easier to grasp.

So I took on my health insurance coverage. I am covered through my employer, but surely I could get comparable coverage as an independent buyer.




I am covered by Anthem Blue Cross.  You know, Blue Cross. The company that used to be the Gold Standard of health insurance? The one my physician no longer accepts because of their reimbursement rates? I figured my best bet was to check out and compare coverage from the same company, so I hit the Anthem Blue Cross website to try and get a quote.

You can get an overview of policies, but they make you put in your phone number so a representative can call you. I didn’t mind, as I had some questions.  I spoke with Danny, who was very helpful.

But before I go any farther, you should know one thing.  Just in case you are looking to purchase a private plan.

If you have insulin-dependent diabetes, Anthem Blue Cross will not issue you a private policy.

Whoa. Found that out when I asked about pre-existing conditions. I had always heard that folks were denied coverage for pre-existing conditions, but to actually hear it coming from a representative floored me.


If I wanted to quit my nursing job tomorrow and make my living blogging (offers accepted), I would need to purchase insurance. I could go with COBRA and buy through my hospital for 18 months, or I could buy my own policy.

The payment for COBRA coverage for a family of three adults (ages 55, 52 and 19) is $2157.00 per month. That is $25884 per year, and includes everything from pediatric well-baby checks to maternity coverage.

Twenty Five Thousand, Eight Hundred and Eighty-Four dollars a year.

Pardon me while I go take a meclizine, just typing that number gave me vertigo.

Private PPO insurance for the same family of three, through the same company, with coverage for brand-name medications is $897, or $10,764 per year.

Huge difference.

On the surface.


To get the private-pay plan you must be vetted. Screened. They will take you if you have high blood pressure, but only if you are controlled and have been on meds for a certain amount of time. Same with high cholesterol.  Same with GERD.  I’ve already mentioned the diabetes. If you don’t meet their criteria, it’s “buh bye”.

My friend in Human Resources told me that our insurance coverage was “more robust” than what was offered in the private plan. Our deductibles are less, our out-of-pocket per-year expenses are less, our co-pays are much less.

She was right.

But I am still confused.

And I have a lot of questions.

  • Why is my employer paying for coverage I no longer need? I’m long past needing the services of a pediatrician and maternity coverage is not an issue (been there, done that, may my ovaries Rest in Peace). Why can I not opt out of these things, saving my employer money? What if I did not want coverage for mental health, for example? The private pay plan is available without maternity care.
  • Why can’t I have the money that is spent on my health insurance premiums (more than some people make in an entire year!) put in a savings account that allows me, as an individual, to choose what type of coverage I want to have?  And have whatever is left available to pay co-pays and deductibles? They are paying the money anyway – why not put it in the control of the patient/employee.
  • Where the hell does the private insurance industry get the authority to decide who they will and will not cover? Is that not discrimination?
  • What happens when/if I develop an illness that would have denied me private coverage to start with?  Am I dumped? Is the illness covered?  For how long?

And I still don’t understand…

  • Why my doctor charges $140 for a visit, I pay $15 and the insurance company pays another $40, and my doctor winds up with only 39% of his fee? No wonder he doesn’t take new patients with Blue Cross.  What other profession has no control over their reimbursement?
  • Why, with my background as a nurse, I still am unable to make sense of an “Explanation of Benefits” report. There is an actual fee, a negotiated fee, a deductible, a co-insurance portion and then what is left is for me to pay. And trust me, the amount paid by either the insurance and/or myself never, ever amounts to the actual fee.  Ever.
  • Why I have a bill for lab tests and screening exams that far exceeds what my deductible is for the year, and yet the deductible is not yet satisfied.  Seems to me I’ve paid out the deductible-times-five and yet it is still not satisfied.

I don’t even know where to start to try and get an handle on this.

Either I’m an idiot or the system is way out of control.

Maybe both.

But I do know this.  I am a 52-year-old woman who is welded to her employment solely for the medical benefits. I’m getting older, I am going to need coverage for conditions and diseases that I did not have to worry about in my 30s.  Every decision I make, whether it be a new job or attending school full-time at a university will be decided by the availability of health insurance and what it covers.

Thank god I have that coverage.

I just wish I had more control over how it was applied.

Lord knows I could do it more efficiently.


  • Rachel

    July 5, 2009 at 8:40 pm

    Imagine what it’s like for us in our thirties. One with type 1 diabetes and high cholesterol when not on a statin, one with type 2 diabetes, hypothyroidism, and mental health issues.

    We are most certainly stuck with COBRA should my husband lose his job or decide to switch jobs with a lapse of coverage (provided I’m with my current employer, which has a catastrophic health plan). It shouldn’t have to be that way. Right?

  • Tanya

    July 5, 2009 at 9:11 pm

    I’ve been running through thoughts of a health care “bank.” But that would still be VERY expensive. Basically pay a membership/administration fee and then pay an amount into your account. Something like a flexible spending account, but without the yearly use it or lose it. Also it would have ways to get lines of credit for emergency events and necessary care. Of course I don’t really see a way around interest there. It also wouldn’t be very attractive for the elderly or disabled, but could potentially be attractive to those who are younger or self-employeed.

  • Harry

    July 6, 2009 at 3:17 am

    Don’t forget that the cost is lower precisely because you and others do _not_ use the services. Insurance works by combining heavy users (like my wife–plasma cell dyscrasia, huge numbers of problems) with very light users (like me). If you let people opt out of the program, the people who don’t need much coverage will opt out to save money, leaving only the people who need a lot of services, which breaks the insurance model. That’s why all the “opt out” plans should be ruled out immediately.

  • GrumpyRN

    July 6, 2009 at 4:28 am

    I had an MI and a CABG 2 years ago, only difference now is I pay for 4 medicines. These I pay on a yearly season ticket and can have any prescribed medicine for that – one payment covers all medicines. My monthly National Insurance has remained the same and I can have as many illnesses without fear, the amount I pay is a percentage of my salary. Current yearly payment for prescription season ticket in Scotland is £38 (about $62). NHS has it’s problems but do not believe everything that you are told. Most bad things you read about ‘socialised’ medicine have been put out by interested parties who do not want to lose money. I have said this before in other blogs – watch Michael Moore’s Sicko, regardless of what you think of him the part where he looks at European medicine is accurate. USA should be looking to other countries and taking the best from them and finding what is best for you, because there are good systems out there but expectations need to change.

  • Margaret

    July 6, 2009 at 7:38 am

    >>What other profession has no control over their reimbursement?
    Kim, your doctor has choosen to take control over his reimbursement by no longer dealing with this insurance company. One of my providers has made the same decision. She provides me with a bill and I submit it to the insurance company and get some of it reimbursed. Your doctor’s office may be willing to negogiate with you directly as well if you think that $140 is too much to pay (your insurance company apparently thinks it is too much for an office visit) but you could see that doctor. You can vote with your wallet by going to a doctor who is willing to take the offered insurance rate, or with your means by negotiating with your doctor directly and paying for it yourself somehow, but either way both of you are in control over that.

  • kmom

    July 6, 2009 at 8:14 am

    Thanks Kim,
    You said it well. I think most people are “happy” because they haven’t NEEDED their insurance. I have private insurance because I got it before I was diagnoised with a chronic condition. Now I would not be able to get insurance if I would like to change policies or this one decided to drop this plan. The policy I have has raised co-pays, raised co-insurance amount, changed what they will cover, and chose how they will apply everything. I cannot go shopping for a better choice. I am trapped.
    This leaves us teetering on the edge of financial ruin.

  • Nikki

    July 6, 2009 at 9:58 am

    While the idea of having patient/consumers own their policies and choose from menus of coverage that suit their needs sounds great on the surface, there are a couple of major problems with it:

    1. Many people in the U.S. have less than a high-school education, language problems, or other issues that would interfere with their ability to manage their health care even if they wanted to. Who will help them choose? (As a public librarian, I got to see that firsthand with the Medicare Part D mess).

    2. Buying health insurance is not like buying a car. You don’t know what problems you will develop or when. It’s very hard to figure out what plan will truly meet your needs when those needs can change drastically and quickly.

    3. Human nature being what it is, many people simply WILL NOT put much thought into health insurance if they don’t absolutely have to due to existing medical conditions. Many people give no thought to retirement planning, either.

    4. Expecting people to be informed consumers and comparison shop for medical services is unrealistic, especially because when you need those services most, you’re probably already sick or scared, and mentally not in a frame of mind to deal with further stress of figuring out various costs.

    Bottom line for me? A single-payer, comprehensive, public health system is the way to go. Everybody pays in (through income, sales, and corporate taxes), everybody gets covered. No plethora of forms to deal with, no plans to figure out. Part of the system should be reimbursement for medical education — say, part of health care provider’s salary would be getting 5% of their student loans paid off per year.

    Tort reform should also be part of the overhaul, so that law firms who bring baseless cases to court get fined for the court costs. If they didn’t do the due diligence to make sure there was a genuine possibility of malpractice (as opposed to a bad outcome resulting from the plaintiff’s failing to get recommended follow-up care), then let them pay for the court’s time, the doctor’s time, and everyone else’s time. Step on the nuisance suits while leaving the door open for suits in a case of genuine, serious harm caused by a screwup.

  • Paul

    July 6, 2009 at 1:48 pm

    Interesting picture. You make good points about it, and I like your social commentary.

  • Annemiek

    July 6, 2009 at 4:12 pm

    Although very far from being perfect, the Dutch system actually has a health care system now where you can pick among plans what you need, such as maternity care. The insurance companies can’t turn anyone away for pre-existing conditions.

  • What was done

    July 7, 2009 at 2:03 am

    Cheer up!
    The age of 52 can be great:
    We are getting old only in our head.

  • Mother Jones, RN

    July 7, 2009 at 3:37 am

    We’re lucky, Kim. We have coverage, for now, but what’s going to happen to all over us Baby Boomers when we are too old to work and can’t get health insurance through an employer. Something has to be put into place now that will help provide coverage, but won’t bankrupt the system. It’s a very scary problem.

  • […] Kim from Emergiblog feels frustrated trying to understand health care insurance. […]

  • AlisonH

    July 7, 2009 at 9:40 pm

    “Am I dumped?” Yes, emphatically yes: go read that LA Times article, they’ve been running an expose and their reporter sat in on the Senate hearing.

    The CEOs of three private insurers testified before Congress that yes, that if you come down with any of 1000-1400 diseases, depending on the company, it is their standard practice for them to fish through your records as far back as 20 years to find ANYTHING that you didn’t put in your application and then dump you for “fraud,” even for some minor thing your doctor didn’t even tell you you had but wrote in your records. They will search till they find a way to deny you on the most frivolous pretense. And they will. Without remorse or ethics.

    Those CEOs should be in jail for fraud, and there is currently no recourse for the individual other than the tort system. We have GOT to change our system!

  • NPs Save Lives

    July 9, 2009 at 7:39 am

    Insurance really sucks and that’s putting it mildly. I pay almost 10,000 dollars a year for family coverage and I have to keep it because my husband has hypertension, DM, etc. I never get to use the policy because I am too busy taking care of everyone else. It’s better than Medicaid though if you have orthopedic troubles in FL. No ortho in N FL will take it. Having to send pts down to Tampa or Winter Haven. Most can’t afford the trips.

  • tim@stock-market-news

    July 10, 2009 at 8:15 pm

    Using your company’s flex spending account option should be a no-brainer. If you were told you could save 40% on your healthcare costs, wouldn’t you do it? I think the FSA and the HSA are the way to go for healthcare. You’re not an idiot. The system is. Not that I have a better answer, though.

About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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