Pleading for the destruction of my industry for the sake of public health.

By an anonymous socialist medical biller in Massachusetts

As someone who became suddenly auto-immune after contracting mononucleosis, and who also was underinsured living at the time in the good ol’ Live Free or Die™ state of New Hampshire — I already had a well-established beef with our privatized for-profit healthcare system. By fleeing to Massachusetts, I qualified for the MassHealth program, and thankfully could confront my newfound disability, finally receiving treatment after only a couple more years of fighting to get coverage for the one and only medicine proven to treat my condition — though I don’t totally blame them for their hesitance. After all, my ‘orphan drug’ medication at the time was priced over $15,000 a month—it’s supposedly $21,000 now. After about a year of being properly medicated and finally healing, I could luckily reattach my supposed bootstraps and drag myself into pursuing work that came with a sweet benefit: Revenge! Or so I naively thought at the time, anyway. Now, with a handful of years under my belt in a small specialty clinic, I’d like to introduce you to the upside down world of medical billing and the pains of navigating the insurance industry.

As utterly boring, convoluted and cumbersome learning about medical billing standards and terminology were, my pure spite for the system and excitement about my newfound health carried me to the finish line. But no amount of training could prepare me for how the health insurance and medical billing system  actually works. Spoiler alert: It doesn’t work. You don’t need to fantasize destroying this particular  system –– it’s already broken beyond repair. Explaining this chaotic and macabre mess behind the curtain means getting into some nitty gritty details that might  make your eyes glaze over from boredom—this is a system that is intentionally designed to be as mind-numbingly confusing as possible. I could never summarize it all but I hope my salt and spice amuses you along the way. You can look forward to a follow up article where I try to give tips to survive and navigate our existing system, you will need a safety helmet for that one! Until then, enjoy the show, but also brace yourself for it; and as you may already know: The exit is on the left.

Nobody knows how the system works

Nobody knows how the system works – including myself. That’s it, that’s all, folks! See ya’ later — and I’m only half kidding. As previously spoiled, it doesn’t work –– and that’s on purpose, so I guess it does technically work. The more we waste time trying to solve this unsolvable puzzle, the more likely we all are to quit peeking and poking behind the curtain,and then more likely one is to accept that the system is just beyond our collective intellect’s ability to understand, thus better left unquestioned…kinda like NFTs!

The only time I’ve had an inquiring patient sincerely understand their insurance, they followed up with “I do this for a living.”—and I too, use this line when handling my own insurance issues. It feels like part of a medical billers’/coders rite of passage as after we respond something like a mournful “Sorry to hear that.” or a sarcastic “Fun, isn’t it?” A medical biller and coder’s job relative to each other is like being the cut-throat accountants of rival gangs dealing in civilian exploitation, except we’re also that same commodity. At the end of the day everything is handed to the boss in typical capitalist fashion. Now, some patients are totally lost, even to the extent of not knowing what their insurance company even is—and sadly that’s not all that uncommon. Then, while other patients may take the initiative to gather information from their ‘health plan’ first before reaching out to us, I learned early on to never take a patient’s word for it and try to verify their coverage myself by asking what I call the ‘right questions’ — I’ll share those with you in the follow up article where I try to help you survive this monstrosity of a system.

I say “try” because the Customer Service Representatives (CSR) for health insurance companies are an extremely mixed bag; they can be anything from reliable enough, to far more confused than our own patients about any given aspect of this failing system. These CSR positions are plagued by the high turnover rates prevalent throughout the call center industry, which means staffers are often inexperienced and under-trained.  I do medical billing for a small specialty clinic, which is probably why we have enough time on our hands  to offer benefit checks for all our patients. But please be aware that the legal responsibility to understand and keep track of insurance benefits, eligibility, coverages, deductible amounts, etc is yours. If your provider, or that insurance representative you spoke with a week ago misinformed you about your coverage (most likely completely unintentionally!)  Guess what? That’s still on you. None of this is taught to ‘we the people’ at any point during our mandatory K-12 schooling, so unless someone is deliberately trying to pursue the not so lucrative field of medical billing (and who would be nutty enough to do that? Oh, right—me!) we all are just expected to naturally comprehend this intensely technical, loop-hole filled language that could dictate our financial ruin and even life and death itself. Meanwhile, more than half of U.S. adults can’t read past a 6th grade level.

Now, many insurers offer an online feature to look up eligibility and benefits (and for some companies, this is the only means of obtaining information); but in my experience, the websites often inconveniently leave out specific details that are crucial for figuring out your coverage. At the start of every call with an insurance company on behalf of my provider, I hear: “Information shared on this call is not a guarantee of coverage, payment, or services.” This lack of accountability –– let alone basic reliability –– makes the already painful and time-consuming endeavor feel pretty pointless! This is also true for patients calling to get information about their plan, you have to hope what you’re told is accurate…unless you get bad news, in which case you have to hope they got it wrong. Which happens all the time! Are you having fun yet? Honey, I’m just getting started. 

All the ways it could go wrong

If I were to attempt to detail every way a medical bill could possibly get messy and ruin someone’s day or life this would be an article of biblical lengths, and neither you or I have the attention span for that. So I’ll keep it to what I most commonly run into; while noting that all the different subtypes of medical billing may experience different (but still asinine) norms. Try to stay awake, this section is the stuff that makes people give up on understanding their health insurance and just assume it works until they get blinded by a bill first hand.

One complicating factor is the number of parties potentially at play, and not the fun kind. Any given appointment can rope a bewildering array of entities into the calculation. Let’s say for example, you have a HMO plan and not a PPO. You’re going to a neurology appointment that your Primary Care Physician(PCP)/General Practitioner(GP) referred you to, so that you can hopefully get help for the chronic migraines our society needlessly gives us. You meet the neurologist, and they submit a prior authorization to your insurance to have imaging approved. Here is how this scenario breaks down into people involved…

• You, the patient seeking help.
  • If you called your insurance beforehand, then the CSR rep who advised you of your benefits.
• Your PCP/GP who submitted the referral so you could see a neurologist.
  • The medical biller on behalf of this provider coding a claim to submit to your insurance.
    • The biller/claims specialist on behalf of your insurance confirming network status and verifying procedures were done in accordance with their contract and your benefit allotment.
  • Whatever department within your insurance company that verifies referrals received.
• The neurologist
  • The medical biller on behalf of this provider.
    • Another biller/claims specialist on behalf of your insurance.
  • The prior authorization department of your insurance verifies if this is allowed in you, the patient’s benefits.
    • Potentially the in-house provider being paid by your insurance company to decide if the requested service is medically necessary/beneficial.
      

We’re now up to 11 people involved with handling your case. Now, let’s say your prior-authorization for imaging gets approved—wow, lucky you! So you go and have your imaging done, which adds another 3 people at least handling this. Hopefully nothing serious is found, because in a couple weeks you’re gonna get hit with a nasty medical bill. You know, those things that are the leading cause of bankruptcy in the USA. Why did you get a bill for a “pre-authorized” procedure? Many things could have happened, especially when so many people are involved and any one of them could have made a mistake in communication, notes or coding. Here are just a few potential pitfalls:

• The provider/techs at the imaging place might have done, or claimed in error to have done more services than were allowed as outlined by the prior-authorization.
• The billers on behalf of the imaging provider/techs could have made a simple typo in their coding and didn’t catch it, causing the claim to not be exactly as outlined in the prior-authorization and inevitably denied.
  • Maybe they forgot to enter the prior-authorization number onto the claim.
• The people handling claims on behalf of your insurance may have gotten confused or made an error and so improperly denied your claim. Laymen people are hired to interpret medical policy jargon afterall.
  • Maybe they forgot to check for a prior authorization number and process it.
• Did you check that the imaging place was in network with your plan? Prior-authorizations don’t always specify a place of service and it’s assumed you’d find one in-network. Remember, that’s your job to know that, and not your doctor’s. They may not have a clue of their own referral’s in-network status. Most specialists you’d seek out should have in-house practices to prevent this; they do want to be paid after all. But not all places take these steps—and they don’t have to.
  • And if said specialist office said “yes” they take your insurance but were wrong, that’s still on you. You need to call your insurance and ask if the provider is, but only after talking to that provider and asking if they think they are, because what’s on the insurance directory is often inaccurate. You need two confirmations not one, and even then are not guaranteed safe. Thankfully if you take those extra steps that’s not too likely to happen, how’s that for a silver lining! 
• Perhaps your bill isn’t as bad as it seems. Some plans don’t know how to deny coverage for a single charge and just deny the entire claim outright. It’s like if you were given a grocery list but because you got the wrong type of cucumber now you have to put everything else in your cart back and starve. Makes sense, it’s all tainted now – ew!
• Perhaps your insurance is a huge scumbag and retrospectively denied your claim.

Anything from a simple typo to blatant corporate corruption could result in you getting face-smacked by a medical bill. I encounter incomprehensible foolishness on any given day while dealing with insurance companies. Not to imply that I’m some hot-shot biller without error; admittedly, I do hereby confess that sometimes…I will make a typo. Honestly I probably do more often than I even realize, but it doesn’t necessarily result in a denial. I feel horrible whenever a typo I’ve caused results in a patient receiving any grief, but I promise you it doesn’t occur due to lack of care. Let me show you how easy this is to mess up:

This is the bottom half of a claim form. You can review here what the full form looks like. This can go by other names: UB-04, HCFA, CMS1500, etc. The above section is where most errors occur; be it the medical biller on behalf of the provider, or the biller/claims specialist on behalf of the insurance company. The information entered into the above demonstration is not from a real case; I just filled random information in to illustrate a concept.  Let’s break this sheet down:

• (Box 17) If a referral is required to get coverage for a specific service, was this received and accepted by the insurance?
  • If so, did the provider’s biller remember to add this to the claim?
• (Box 21) These are International Classification of Disease (ICD) codes, basically each line filled in, is what the patient is diagnosed with and being treated for. You can look up ICD code definitions here.
  • This is a very common area to mess up, not in the context of making a typo, but in the context “Did the patient, doctor, and/or the insurance rep that the patient or doctor spoke to read the fine print to get coverage approved?” A lot of coverages are diagnostic specific, and have to be specifically asked about.
• (Box 23) When your insurance approves a Prior-Authorization, they give your provider’s office a code to indicate approval that needs to be present on the claim form.
  • For some reason insurance companies frequently miss that I’ve filled this in, and it’s incredibly frustrating because it means a long phone wait, and having to explain to 1-3 people at the insurance company they messed up. Which can take days to months for them to fix. Ah, the thrill of the chase to catch claims and gnaw the evil insurance companies wallet…is a lot less fun than I thought it would be.
• (Box 24-A,B) Date patient was treated and where they were seen. 
• (Box 24-D)Current Procedural Terminology (CPT) codes are indicators to what treatment the provider rendered during the visit. You can look up CPT code definitions.
  • Was the correct modifier used if needed?
    • Some codes require other codes to be billed alongside them in order to process. Were those forgotten–even on one single line?
      • While your treatment may have been approved, maybe something during your treatment wasn’t. Like if another medical issue was discovered after the fact that wasn’t pre-approved.
        • Yes, you’re supposed to be psychic and know these things! 
• (Box 24-E) Diagnosis pointer, is making the connection between the patient’s diagnosis (ICD labeled in Box 21) and the treatment (CPT on that same line). For example: If a doctor is treating shoulder and knee pain, but the insurance only allows injections for the shoulder, the biller will indicate in this spot the ‘injection’ was only performed on the shoulder. Putting the wrong indicator on any single line could trigger an overall denial.
• (Box 24-F) This is what the provider charges for each service. Not to be mistaken with what the provider gets paid by the insurance. When a provider enters an insurance network, they have a contract that in exchange for being allowed to treat more patients, the provider accepts a lesser rate. Claims submitted still have to reflect what the provider charges to all insurances, even though the provider knows that’s not what they’re going to get paid.
• Because of this, many providers will set their official fee schedule to reflect that of the best paying insurance contract. This is also how health insurance talking-points trick people. They’ll show patients the provider charged $50 on the claim, but when the claim denies, the insurance will say to you “But you only owe $37 instead because you’re our member.” What’s really going on here, is that the provider is likely fine with that lower rate, they just want to be able to treat more patients (and be paid reliably). Health insurance companies gate-keep patients from doctors with the ‘in-network’ aspect of the system. 
• Additionally, the rates set for insurance companies can differ greatly from the out of pocket rates for those who don’t have—or choose to hide the fact that they do have insurance coverage. The article linked here asks “why would it ever be cheaper to go out of pocket than to go through an insurance with a high deductible?” That’s because medical billing is a HUGE hassle and a waste of administrative time.Time is money. Out of pocket discounts are most often labeled “Pay at Time of service” discounts. The legality of this varies state to state.
• (Box 24-G) I loathe this one. In the example claim above, you see there is one unit of 97002, which is charged at $40. Beneath that, is two units of 97140 which are charged at $100.00 (which means to convey that each unit is actually $50.) Not all insurance plans want units expressed easily like this though, randomly many others require they be written the way depicted below. Not all plans are forthcoming about which way they want billing submitted and thus new billers/new provider offices—or everyone if a new insurance company enters the market/netowrk—needs to experiment to see if it gets denied and jot down on their growing desktop strategy guides what method each insurance wants. Maybe this small example does not seem that difficult, but a biller having to change their method of formatting for every other or few plans they submit billing for—which can be extremely dense with coded information— can make the billing process incredibly more daunting than it already is, and it’s entirely unnecessary! The below example is intentionally simple, now try imagining what billing for something like childbirth would look like when things like basic supplies and even skin to skin contact with your newborn are billable to patients.
  

Anecdote: How hard can it be for a professional like me to navigate?

Rebecca is a patient in her 50s who suffered from constant pain related to a birth defect. She took the initiative to look up her own insurance coverage online, where it informed her that she is entitled to 20 visits a calendar year for one of our services. I also checked online on her behalf, and the only additional information  the provider website offered vs the patient website was that the treatment was only covered “for the treatment of chronic pain.” Okay, she has chronic pain –– so far so good.

Nonetheless, I always call the insurance directly if they give me that option—most do. I ask my flurry of questions. I learned that coverage additionally requires a referral from her doctor. Why doesn’t the website say this? I couldn’t tell you. Some insurance websites will even state the opposite of what a CSR tells me. It’s a coin flip which one is the truth. It seems insurance companies don’t have an obligation to provide accurate and consistent information across platforms, but if they are legally obligated, clearly no one is enforcing it.

Rebecca’s doctor had no issue with the suggested treatment. He processed a referral with her insurance and sent us a copy for our own records and the provider I work for began treatments with Rebecca. In her case, her pain would subside for 3 or 4 weeks before needing to return ––  unfortunately, there is no curing her condition. On visit 13 her insurance rejected the claim and mailed her a bill— before we even noticed the claim denied, something more common in smaller specialty offices than larger scale facilities. I hate that some insurers do this, because frequently the insurance makes a mistake in rejecting the claim, which we can correct before the patient has to hear bad news. Sometimes I might have made a typo and just need to resubmit the claim. There is no need to horrify patients with a bill. We’ve had—thankfully very few— patients prematurely end care and essentially flee in fear that we’d be hitting them up for money, when in reality they didn’t owe anything! We just needed a little more time to make sure the claim was processed correctly. Thankfully, Rebecca was very communicative with us, and I assured her I’d be looking into it.

I first checked on the insurer’s provider website to see why the claim was rejected. The website stated that the claim “exceeded benefit limits,” but didn’t further specify what aspect of Rebecca’s benefit limits was supposedly exceeded. So I called her insurance to speak with a claims specialist. This conversation is paraphrased from memory and fast notes I took from back then:
____________________________________________________________________________
Melinda – Claims Specialist: I see the rejection is because the patient exceeded their benefit limits.

Me: I understand that, but what aspect of the benefit is exceeded? Both the plan website and a CSR from this plan informed me Rebecca has 20 visits a calendar year for chronic pain so long as she gets a referral—which we have documented on this claim.

Melinda: Let me look, please hold. (time passes.) Sorry for putting you on hold for so long. It looks like per this member’s plan, she can only use this benefit within 90 days of her first appointment before it triggers a prior-authorization requirement for more visits beyond 90 days.

Me: That doesn’t make any sense. We’ve been paid for a couple of past claims for this member that occurred after the 90 days from when we first started seeing her.

Melinda: Ah yes, I encounter these sorts of errors all the time, you will be very lucky if the insurance doesn’t request you send back the payment from those visits.

Me: Am I understanding you correctly? A patient is entitled up to 20 visits a year, but they must use all of them within 90 days…even if they don’t need treatment that frequently?

Melinda: Yes, that seems to be the case.

Me: Could I speak to someone else about this? I’ve never encountered something like this in a benefit, and I’ve encountered a lot.

Melinda: Okay, allow me to just double check with my manager. Please hold! (More time passes.) Alright, I have figured out the problem. This patient actually only has 12 visits a year.

Me: That completely contradicts the website and the CSR I spoke with.

Melinda: Oh? Do you have a call reference number?

Me: Yes, it’s (insert number here).

Melinda: Hmm, nothing comes up when I type that in. Not sure what to tell you. But I am glad we solved the problem for you.

Me: We didn’t solve any problem, though. First you said she needs to use all of her visits within 90 days and that we’ve been improperly paid for visits that exceeded 90 days—because she doesn’t need excessive treatment. Now you’re saying she has 12, not 20, visits, even though  the provider portal website, right now as we speak, shows she gets 20 visits a calendar year.

Melinda: Okay, let me ask my manager…(time passes). Ah, we have figured it out! The patient is entitled up to 20 visits a calendar year. But visits exceeding 12 require a prior-authorization and no more than 8 additional visits can be approved in a calendar year.

Me: 12+8=20…I see, that would be more believable for an insurance company to pull. Sure. But what of the 90 days thing you were saying?

Melinda: In my humble opinion, it is likely both factors that caused this claim to be denied, but hopefully they won’t ask you to repay back the claims that went through! Can I help you with anything else?

Me: No offense, but humble opinions aren’t helpful, but I understand the system is incredibly difficult so I do sympathize with you. I’ll try to get clarity elsewhere—thanks.
____________________________________________________________________________

I call Rebecca back to let her know I’m not confident I’ve received accurate information yet. Rebecca asks me to speak with her doctor to see if he might be able to help. I call and he’s livid that the insurance is denying her claims for treatment. No one wants to place her on opioids for pain management. On their end, Rebecca makes an appeal for coverage to be reconsidered and a few days later I get a call from her insurance company –– this time from the prior-authorization department, who thankfully had more answers for me.

Essentially, the reason they denied the 13th visit that year was indeed because of fine print stating she actually only has 12 visits guaranteed and needs prior authorization for visits beyond that, with no more than 8 additional visits allowed within a calendar year. That whole situation was so bloody asinine that the provider I work under happily ate the loss for Rebecca— but I needed to make sure there was no discrepancy with the supposed “90 days” restriction that Melinda the Claims Specialist had mentioned, so I asked the Prior Authorization department representative about it. Let’s call her Julie.
____________________________________________________________________________

Julie: That doesn’t make any sense to me, I’ve never heard of such a thing.

Me: Same!

Julie: I honestly have to assume she was talking out of her butt.

Me: I’m sorry to be a pain in your butt, but I really need solid clarity here, I’m sure you know what they say about assuming…

Julie: That is fair, I will ask my manager to look over this plan benefit with me. Please hold. (Time passes.) I am back, and much to my and my managers surprise there is indeed something written here about 90 days.

Me: So Melinda is vindicated, huh?

Julie: Well, the benefit is not exactly clear? I’m confused about the wording myself. It reads: The patient can have up to 20 visits a calendar year for the treatment of chronic pain. Then further down the page it says: Up to 12 visits in 90 days will be allowed, after that a prior authorization is required for no more than 8 additional visits. I don’t know how to comprehend that.

Me: I would take that as meaning that Rebecca can’t run through those first 12 visits faster than 90 days. As in, any request for an additional 8 visits would not be approved until it’s been at least 90 days since her first visit.

Julie: That makes more sense in my head than the other interpretation, at least. It could definitely be worded better. But I do see a likelihood you might face random rejections based on this, so I’m going to add that interpretation of the 90 days rule to her record. If in the future it ever comes up again, you can give the claims department my name and direct line.
____________________________________________________________________________

In my experience that was a surprising thing to have happen –– a direct line to a helpful person at an insurance company? That’s incredibly rare. With that concern out of the way, I typed up a new prior-authorization for Rebecca to get her an additional 8 visits for that year. Rebecca’s doctor supplied a new referral along with a lengthy letter to be sent in with it.

The Prior-Authorization was rejected.

On the grounds that Rebecca does not have a qualifying condition. You see, we learned she could only get those 8 additional visits if she was demonstrating improvement. In most cases that’s not a bad thing. We wouldn’t want our system being drained on something not working of course! But Rebecca’s condition cannot be cured. It’s a birth defect; we can provide her symptomatic relief and a life without pain killers but we can’t, at least not permanently, improve the actual cause of her pain. We submitted an appeal along with a new letter from her doctor insisting this was medically necessary as no previous treatment methods have worked to relieve her, but the definitions are what they are and the appeal was denied on the same grounds..

Instead, our provider took Rebecca on as a pro-bono patient during the in-between coverage periods. Once January arrived, her plan renewed those 12 visits, which she can always have so long as she can get a referral—which her doctor is happy to provide.

Then suddenly, in year two of treating Rebecca, coverage for one of those 12 guaranteed visits was  denied with the same tagline: “exceeded benefit limit.”  I called the insurance up, and essentially had the same conversation that I had with ‘Melinda’ about the “90 days” rule in the benefit description.

I first gave them Julie’s information, as well as the reference number from that call. Which surprise, surprise— couldn’t be found. Julie also allegedly no longer works there and can’t help me anyway. I politely instructed the claims specialist to read the benefit back to me slowly, and gently try to insist on my interpretation. The claims specialist admits she is confused and asks to place me on hold. If you can’t tell by now, my job is a lot of being put on hold whenever I have a question. I have the low-quality, static heavy ‘on-hold’ elevator music of every insurance company memorized and haunting my dreams.

After a long hold, the call disconnects. That makes me want to spider-climb up a wall and breathe fire every time it happens, but I keep my outer cool and call again, waiting almost an hour to get someone else. The same conversation ensues, I am placed on a new hold now before ‘the manager’ answers. She is very unhappy that I’m arguing about this definition and instructs me to submit an appeal as they won’t look at this any further. So I write the new appeal, get another letter from Rebecca’s doctor to supplement, and attach all the notes and call dates from the discussion with Julie from over a year ago and submit it.

Thankfully the appeal was approved. Except they denied a future visit again a while later for the same. damn. thing. But thankfully this time, I only had to call them and reference the most recently approved appeal and they fixed it on their end instead of making me jump that extra two hoops— I’ll take what I can get. Did you head spin trying to follow all of this? My neck is beyond Regan MacNeil’s possession at this point. They say doing the same thing and getting no results means you’ve lost your mind, so I guess my actual job is to go well past that point.

Please consider how much time I spent on this one case, and consider how much of a financial burden this system is to manage. Not just for myself, but the provider who should be allowed to focus just on treating patients and not doing all this extra book-keeping, fighting, and hunting. It’s excruciatingly wasteful, and Rebecca received 3 medical bills throughout this process that she didn’t actually owe anything for. These errors happen incredibly and inexcusably often. I did everything I was supposed to do for my job and more here, and still had an uphill battle to get to a conclusion with this case. Insurance misinforming myself or our patients like this is a regular Tuesday for me.

Dismantling the “Choice” argument

While not trying to insinuate they are infallible: your doctor went to medical school and likely threw themselves into significant levels of debt to be able to practice. They see you, the patient, in person and hear your tone, physically evaluate your constitution, run through the facts and hopefully have the best interest for you. Nothing wrong with getting a second opinion of course but in this context, the opinion coming from the person working on behalf of the for-profit insurance company— who you the patient will never meet— THAT person gets to call the shots?

If we snapped our fingers and created a single payer system, that wouldn’t be the total end of medical billing, because someone would still have to submit claims to the government. And capitalistic leaching would still exist as healthcare remains a private business for clinics and hospitals. But short of finally being able to achieve socialism, the ability to send everything to one place with one set of rules, versus a hundred different places a hundred different ways would significantly reduce the need for people to do my work. Not just mine, but many other jobs relating to the private insurance system would cease to exist—and that is perfectly okay. Should we never have industrialized anything and made society better for the sake of the farmers’ blood-sweat-and-tears jobs? Of course not! This all only remains a scary thought because of capitalism dictating a workers ability to survive based on how lucrative their labor is for the capitalist owners. Once a capitalist can’t feed off our labor, our strings get cut like a marionette. However, at least in this case, the Medicare for All Bill as it stands offers a 5 year safety net for those of us with jobs that get impacted. While the transition to single payer system would definitely be rough at first, in the longer game and bigger picture within our capitalist hellhole, it would save money, save lives, and help other fields to expand jobs of better quality and empower workers.

I often hear the argument: “We should have a public option, it would be the best of both worlds! For those that like their private insurance, they can keep it and those that don’t, can switch off. Easy peasy!”  This freedom of “choice” is an illusion, and I think it comes from a fundamental misunderstanding of the concept of insurance as well as from the fear that covering more people means higher rates or longer waits — but neither are the case. And we’re already experiencing fast growing wait and cost increases with our current system anyway, while achieving far lesser results. I’d like to remind such a reader that I waited years to get help for my auto-immune disease because I was underinsured – that would not be an issue in a singular universal healthcare system.

By pushing to defend the ‘choice’ of public or private insurance coverage—that’s assuming you’re one of the majority of Americans whose employer already dictates which insurance you have, thus preventing many the choice of leaving their job if they can’t afford COBRA— you are actually choking yourself off from thousands of choices of providers and facilities that would be available to you nationally. Now that doctors, especially primary care physicians, are fast exiting  the field or avoiding it altogether, finding people ‘in network’ let alone in a timely fashion, is becoming more and more impossible to navigate. Even if that isn’t your experience yet, it’s coming soon to a theater near you.

The insurance lobbies may have convinced the masses that merging all coverage into the public sector is impossible and costly—which is a hilarious argument considering they have fraudulently taken billions from medicare—but health insurances are already merging as bigger profit giants swallow smaller ones and because they’re merging for profit incentives, costs rise! Deductibles alone have risen 150% in the last decade, and over 40% of people enrolled in the ACA marketplace are considered underinsured as a result of this rise and other out of pocket expenses.

So long as private insurance companies exist in the same form as they do today in the US, even with a public option these are just a few of the problems that would fail to be remedied:

• For every one hour of face to face time with patients, providers will spend 2 hours of EHR and clerical work.
• About half of a provider’s administrative costs are billing and insurance related expenses. (Hello~ it’s me! I’m paid to be on hold for hours with your insurance.)
• Our taxes are subsidizing the private insurance industry despite record breaking profits, and insurers have sued our government to ensure they are paid.
  • A public/private system will eventually have the same issues, as currently experienced within Australia’s system.
• Claim denials are up 23%, because it isn’t profitable to help give people the care they need. 
• The power of the private insurance industry would likely lead to the gutting of any legislation to create a public option, much like what happened with the woefully inadequate Obamacare. These inadequacies will then be falsely painted as the reason to not ever switch to a single payer system. Like all things with capitalism and a lack of true democracy, a public option will be easily dismantled over time just like Roe v Wade was. Whatever measure we may achieve, it will be dragged to the right until we end capitalism. That’s why it’s so important in the meantime to fight for the biggest ideas and protections unapologetically – you aren’t likely to land there.

Even more ideal would not just be a single payer system, but a fully nationalized healthcare system where hospitals and medical facilities are a public good and not a for-profit business trying to sneak and maximize charges—which unfortunately is still not yet a popular idea here but support at least for a single payer system finally seems to be happening which if achieved, can allow for the government to dictate rates. This is all said of course, while knowing our government is bought and paid for and not going to support the right thing on their own no matter how much we call, email and beg them. Studies show popular opinion does not remotely influence policy, policy is influenced by elite interests. That is why ‘we the people’ need to organize and demand it. But to get true healthcare justice, we have a lot of work to do to clarify capitalism as the cause of our misery, and socialism as the anecdote. Social democracy isn’t enough and isn’t immune to their healthcare systems being dismantled. The only real way to lower costs is to centralize our healthcare system for the sake of wellness—not profit, which is the antithesis to capitalism. We are looking at a long struggle ahead of us to achieve this, but knowledge is power and when there’s a will – there’s a way. I have a theory of change on how to go about eliminating my job, if reading all this has made you angry or further despaired – let’s channel that into something more productive!

Eliminate my job

I had a phone call with a CSR at an insurance company once who was so lost and confused, that when I asked her to transfer me to someone else she whispered on the phone: “Please don’t, I might get fired.” If we professionals trained to do this can’t smoothly and confidently navigate this, let alone the fact that we encounter many detrimental errors that could tear a person or family apart—why keep it? There is no justification for this in the interest of humanity beyond blind, toxic nostalgia for a siren’s song of lies. Why should anyone have to potentially face a medical bill of ironically life shattering proportions, particularly only to the benefit of the ultra rich? Our existing healthcare system is broken beyond repair, we cannot reform our way out of it. CMS has already twisted itself into knots trying to fend off corporate exploitation from maximizing billing—and failed. There’s just not enough oversight and the elites are steamrolling ‘we the people’ in all sectors, many with deadly results for the sake of profit like recently seen with the Ohio Trainwreck.

I live in continual fear of my health insurance suddenly changing and then losing coverage for the now $21,000/month medicine that helps manage my auto-immune disease. I help my friends and family tackle their medical bills tangled and littered with messes that function only to benefit corporate greed and exploitation. One of my dearest friends took his own life, he had permanent full body pain after a vehicle accident that left more bones in his body broken than not—he was someone considered ‘underinsured’ and was waiting too long to get prior-approval to receive help and was denied disability multiple times for lack of a stronger medical ‘paper trail’ documenting his immense suffering. He didn’t have enough of a trail, because he couldn’t afford the time off work and specialist copays in addition to rent, and food. My friend was forced to continue working to try and make ends meet—until he physically couldn’t anymore. This to me isn’t suicide, its murder.

The elites rely on people not understanding the far reaching implications of Capitalism which is exemplified in our healthcare system. They rely on us feeling too overwhelmed to comprehend the macabre mess behind the curtain, and being too distracted to come together. Many have died being forced to try to detangle and find their own incomprehensible way out of our complicated healthcare system—only to get claimed by it. It’s a ritualistic sacrifice in the name of profit—and as dramatic as it may sound, the simple fact is: It could happen to anyone. The “It hasn’t/can’t happen to me so it isn’t a real problem” mindset is something advocates and activists chronically bump heads with in regards to all social justice topics. With the pandemic, many have had to confront our healthcare reality for the first time, of which over 200 thousand lives could have been saved if we at least had a single payer healthcare system. If you’re a working class person, it’s a matter of when—not ‘if’— one will be forced into the long line to our rapidly crumbling health system; especially since contrary to popular belief: the pandemic is still ravaging and clogging up access to care. Let alone the growing number of people suffering from Long-COVID.

So, what’s the solution?

First, is understanding what we have to leverage. Our system is the way it is, to help maintain and bring about annual record breaking profits at the expense of our comfort and survival. Suddenly putting seat belts on profit addicted swine isn’t going to stop the forward trajectory of crashing. Begging our politicians that are beholden to these morally bankrupt, flesh bags of greed isn’t going to cut it either. We have to hit them where it hurts – the source of their profits: our labor. The only good thing realized from our current reality is a huge comeback of union organizing which is leaving some CEO’s whining about even the most mild changes that give workers a smidge of a leg up. And in terms of healthcare, nurses all across the country have been organizing and striking to give YOU better care.

History has proven the best strategy to we the people improving our lot and extracting change is through labor unions. If we could come together in struggle across multiple industries demanding change, the capitalist class will do all it can to stop the momentum of people, but ultimately can be forced to cut off the targeted industry of people’s demands that threatens all other capitalist profits. That would be winning the battle, but not the war. Struggle is a constant, and climate change is rearing its ugly head faster than we are responding. Once the pushing starts we must not secede ground if we wish to bring about true multisystemic change— only we can save us. So stop waiting for a savior and look in the mirror, if it’s on us it’s on you too. Easier said than done of course, even just talking about unionizing in these times can be an intimidating first step to take— but you don’t have to go at it alone nor blindly, friend! The exit to get off this hellscape is on the left with groups like the DSA who have been organizing in support of Medicare for All before it was cool. Regardless of membership, you can reach out to the DSA’s Emergency Workplace Organizing Committee – it’s completely free. Someone will get back to you and help clarify any questions you have and hopefully find a path forward to securing a union. Please help eliminate my job, by organizing at yours and joining a socialist organization to help spread the word. “Each one, teach one.”

Solidarity in struggle,
— A tired socialist medical biller in Massachusetts