Why September 23rd Matters


I am supposed to care about health care reform because (1) I am an American who votes, (2) my job requires me to care about it, and (3) as an above-knee amputee, anything having to do with health care potentially affects how I live. But I don’t care about health care reform at all. That’s because the passage earlier this year of the bill that will either, depending on whether you watch Fox News (“Fair and Balanced”) or MSNBC (“The Place for Politics”), result in a Socialist State or a modern Utopia, does not reform health care.

It does, however, reform insurance. And I care about insurance reform because through simple happenstance I’ve spent most of my career dealing with insurance companies. My interest in insurance-related issues signifies just how boring a person I am. In fact, to the extent that anyone finds me interesting, I believe their opinion of me arises out of a lurid fascination with a creature that talks passionately and unrelentingly about insurance. I am like a Jack Johnson song – I’m so boring that, inexplicably, some people find me compelling, convinced that there’s something more than what’s actually there. I can assure you, there’s not.

Anyway, you may recall a small national debate earlier this year about insurance reform, complete with obscure Congressional parliamentary maneuvers, proclamations of damnation/salvation, and, ultimately, 2000 pages of text that make a lawnmower instruction manual read like Hemingway in comparison. Optimist that I am, I’m going to focus on the insurance reform law for the next 2000 words, as three of its provisions that theoretically benefit people with limb loss/difference take effect this week (September 23rd). And I am going to do that, ideally, without any of you first trying to dig your eyes out of your skull with a spoon. So crank up the Jack Johnson and let’s go.

1. A Nearly Limitless Future

Most insurance policies have a “lifetime limit” provision. Contrary to what that name might suggest, the lifetime limit does not speak to the total number of alcoholic beverages you are permitted to consume before you die, nor does it refer to the age after which your insurer sends out blank-faced assassins to terminate you (though that would solve the problem of exploding health costs in the final years of life and give entirely new meaning to the term, “death panel.”) Instead, “lifetime limit” refers to the total dollar amount an insurer is responsible for paying during the time that they continuously insure you.

So, for example, imagine that “On and On Insurance Co’s” policy has a lifetime limit of $2,500. (There is no insurance company with a name “On and On”, nor is there a policy with a lifetime limit of $2,500. But I believe absurd scenarios are better teaching tools.) Further assume that you like skim boarding (a cousin of surf boarding that involves sprinting across the beach while tossing a shorter, fatter, and lighter version of a surfboard onto the receding surf and hydroplaning on about 1-3 inches of water for short distances.) Finally, accept for the sake of argument that on this sunny summer day, with your “On and On Insurance Co” card tucked firmly into the snapped side pocket of your appropriately baggy swim trunks – notice that no one surfs or skim boards in Speedos, which is an argument for every American at least nominally taking up some kind of board-related water sport – you arrive at the beach to find a preternaturally strong and gusting wind that has forced most sunbathers to cover one side of their faces with their towels to prevent the flying sand from giving them an all-natural exfoliation.

One of these explosive wind gusts catches your skim board as you hold it by your head while preparing to launch yourself down the beach. Due to the board’s aforementioned short, fat, and lightweight design, it functions nearly as well as a wind catcher as it does a water-riding-instrument, and the fiberglass tip of the board crashes into your forehead, opening up a 30 mm (I like metrics) gash over your left eyebrow.

After the plastic surgeon has finished draping a hospital-blue paper shroud over your face with one small hole exposing the “surgical field,” injected an anesthetic directly into it with a needle and syringe that once played a lead role in a Cold-War-era film involving a captured American spy, and tied off the last of the 3 stitches closing the wound, you have (congratulations) exhausted your On and On lifetime limit of $2,500, as the plastic surgeon charges you $3,500 for his 17 minutes of work. From this windy day forward, On and On Insurance Co no longer has any obligation to pay for your health care, having fulfilled its obligation to pay for your costs up to your lifetime limit.

In the much-less-interesting real world, insurance policies have higher lifetime limits than $2,500. But even so, certain medical conditions can quickly surpass those amounts, leaving you a premium-paying yet uninsured person.

For example, if you fall asleep at the wheel of your car and drive into a tree, resulting in a 45-day hospitalization/in-patient rehab stint with multiple serious injuries, including the amputation of your right leg below the knee, it’s entirely possible that you will be staring down the barrel of that lifetime limit disturbingly soon. (Assuming you bravely fight through the injuries to return to your job and the group health plan it offers you.)

However, for state-regulated insurance plans renewed or issued this Wednesday or later, insurance companies can no longer impose a lifetime limit. (For a discussion of the difference between state-regulated plans on the one hand and ERISA-based (self-insured) plans on the other, click here. So, in the post-Tuesday world, On and On Ins. Co would not only have to pay the entire $3,500 plastic surgeon’s bill for the painful day at the beach, but all other covered costs you incurred after that. Similarly, when post-Tuesday you requires a new below-knee prosthesis, your post-Tuesday insurer that renewed or issued a new policy cannot refuse to pay for that prosthesis on the ground that you exhausted your lifetime limit. That will make post-Tuesday you happier than pre-Tuesday you, as post-Tuesday you will not have to choose between (a) selling the house, and (b) getting a medically necessary prosthesis.

Incidentally, the skim boarding incident is real – my son was the lucky recipient of the stitches over his left eyebrow. Because he injured himself outside the United States while vacationing someplace that is subject to the Dutch health-care system (read: true government-run health care), our total costs for that injury, including the follow-up visit to the surgeon who stitched him up, were only $300. In contrast, when his younger brother got the same number of stitches in his face a few years earlier after being struck by a baseball bat at the local ball field, his costs were the previously mentioned $3,500. From this story, we learn that another solution to America’s insurance problems is for all US citizens to move to Holland or Dutch-owned territories.

2. No Matter How Old They Are, They’re Still Your Kids

The long-term success of insurance reform rests in significant part on the ability of insurers to capture premium dollars from “young invincibles.” When hearing this phrase, I reflexively and immediately imagine Emilio Estevez and Kiefer Sutherland walking bravely through dusty, tumble-weed-filled streets, bottles of penicillin and hydrogen peroxide in their holsters. I also believe, despite no mention of it on imdb.com, that Sutherland appreciates socialized medicine as a result of his father’s Canadian citizenship and his being born in England. And I further hypothesize that because of Kiefer’s innate understanding of the Canadian and English health care systems, and his Hollywood-based exposure to U.S. health care while playing agent Jack Bauer on Fox’s 24 – who, in a thoroughly underdeveloped storyline, must as a government employee enjoy the coverage provided by TriCare – he agrees with the conclusions of Michael Moore’s Sicko and believes that it is a great film. I have no way of validating this.

Sadly, “young invincibles” much less dramatically refers to people between the ages of roughly 18-30 who, because of their callowness and limited life experience, elect not to procure health insurance because they are, after all, in the bloom of good health and constitutionally incapable in their own minds of falling ill or getting injured. This proves (again) that the world inside my head is more interesting than the world I actually live in.

The reason young invincibles play such a large role in the potential success of insurance reform is that most of these people do, in fact, require relatively little health care. The more of these indestructables who, despite their superior health, choose to obtain health insurance and pay premiums, the better it is for me, you, and the other sickly people who comprise the “old breakables.” That’s because if young, healthy people pay premiums but generally avoid incurring costly medical care, the money they contribute to the system can help offset the comparatively high costs that the sick and infirm generate. It’s a yin-yang thing.

The problem with young invincibles is that, left to their own devices, they often refuse to obtain health insurance, because of their previously mentioned callowness and limited life experience. So, Congress – which most citizens think of in the same way they describe their parents: a for-some-reason necessary-but- generally-annoying authority figure that thinks it knows everything and always butts in where it isn’t wanted – gave actual parents the ability to assert that they [actual parents] know everything and butt in where they aren’t wanted when it comes to their children’s insurance-related matters. And Congress did this by permitting “children” to stay on their parents’ insurance policy until the age of 26 (up two years from 24). I conclude from this that Congress believes that childhood ends nearly half a decade after someone graduates college.

I have no confidence in my elected officials.

So for state-regulated insurance plans renewed or issued this Wednesday or later, parents can keep their precious “babies” on their insurance policies up to the age of 26, provided those very large children do not have insurance available to them through their jobs. (If, by some miracle, your less-than-26-year-old child does have a job, and even more miraculously, that job also offers your child health insurance, then you cannot keep them on your policy till 26, even if your kid does not select the plan offered by her employer. In contrast, if your out-of-work-less-than-26-year-old child spends her days eating pints of ice cream in your basement while repetitively watching Donnie Darko, you can keep that lovely lass on your policy till the ripe old age of 26.)

This makes perfect sense. Apparently, Congress believes that slacker kids deserve greater protection than responsible ones. Which leads me to conclude that a study of the children of our duly elected officials would reveal an inordinately high percentage of Ben & Jerry’s afficionados with a stalker-like affinity for Jake Gyllenhaal and a surprising knowledge of the theoretical world of six-foot-tall nightmare rabbits that walk on their hind legs.

Bottom line: Congress has effectively codified the following principle: parents have the right to stick their noses into their kids’ insurance business far longer than they have a legal right to control virtually any other aspect of their kids’ lives. For young individuals with LL/D who do not have insurance available through work, that means you now have access to your parents’ policy, and the prosthetics hopefully covered by that policy, for an extra two years.

3. The Benefits of Youth

Certain concepts defy easy explanation. What separates “good” art from “bad” art is one such concept. The success of Jersey Shore is another. And then there’s the pre-existing condition exclusion in insurance policies.

Stripped of all its complexities, the basic principle of the pre-existing condition exclusion is this: if you have a previously diagnosed condition, your new health insurer can legally refuse to pay for medical treatment related to that condition for some period of time. As you can hopefully figure out yourself, limb loss/difference is a pre-existing condition. And this exclusion is particularly onerous for people with LL/D because the cost of prosthetics is so high that few individuals can afford to pay it out of pocket.

For most state-regulated insurance plans renewed or issued this Wednesday or later, the insurance reform law prohibits those plans from asserting pre-existing condition exclusions against children less than 19 years old. So where today an insurer could deny a claim for a new prosthesis for an 18 year-old above-elbow amputee based on the pre-existing condition exclusion, that same insurer would likely have to pay for that same prosthesis under a policy renewed or issued after Tuesday.

You will, if you are paying attention, note that Congress considers children to be children up to the age of 26 when deciding whether they can stay on their parents’ policies, but only considers them children up to the age of 19 for purposes of the pre-existing condition exclusion. So, to summarize, (1) Kids can drive a car at age 16-17 (in most states); (2) already-disabled kids escape pre-existing risk exclusions until age 19, and (3) insuranceless kids can stay on their parents’ policies till age 26.

From this, I conclude that our elected officials are more comfortable letting texting-impaired teens distractedly drive their SUV’s off the road all across the country than they are requiring health insurers to pay over the long haul (i.e., past age 19) for the injuries resulting from said accidents. And when mangled youth then can’t get work past the age of 24, Congress is happy to give parents the opportunity to pay their kids’ insurance premiums for an additional two years.

This is too sinister and cynical to be true. I therefore believe it.

This brings to a close my highlights of the “big three” insurance changes taking effect this Wednesday. But one final point before I collapse in excitement from this news: since many insurance plans run on a calendar-year basis, the “September 23rd” changes may not actually take effect for you until January 1, 2011. So before you print out this post and march into your HR department on Wednesday, brandishing it obnoxiously in the face of your cowering head of HR, it would be prudent to first understand when your policy year begins. No point in being put on a “professional development plan” simply because, like me, you are interested in insurance reform.

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