My Insurance Company Killed Me, Despite Obamacare - DailyBeast

[WillyT]

My Insurance Company Killed Me, Despite Obamacare
Malcolm MacDougall, a prominent speechwriter and creative director, was diagnosed with prostate cancer earlier this year. Even after the passage of the Affordable Care Act, his insurance company delayed and denied cancer treatments despite MacDougall paying his premiums. This is his story, in his own words, written five days before he died.
Malcolm MacDougall - DailyBeast
11.24.14

<snip>

How far will a health-insurance company go to deny coverage when you are really sick?

How willing are they to risk their customers’ health and possibly their lives? Well let me tell you my experience with Health Republic and its affiliate MagnaCare.

For five months—ever since I was diagnosed with stage-four metastasized prostate cancer—they refused to pay my medical bills. On Oct. 20, a nurse with Health Republic overruled my oncologist and my primary-care physician and declared that a critical test to determine the progress of my cancer was unnecessary.

It seems she was wrong. As a result, I am writing this from Lenox Hill Hospital, where I am undergoing emergency tests and treatments ordered by three prominent New York doctors who didn’t agree with that health-insurance nurse.

This latest fiasco is not at all surprising. I have been fighting to get Health Republic and MagnaCare to explain why they suddenly and inexplicably refused to pay for my doctors and my treatments even though I followed their rules for members, went to their online list of providers, and actually received two form letters stating the treatments the doctors had ordered were legitimate.

It’s a long story, but if you want to know what it’s like dealing with the health-insurance bureaucracy when it’s a matter of life and death, you might want to stick with me.

My health-insurance company has refused to explain why, on every visit, these doctors accepted my Health Republic/MagnaCare card, and assured me I was “in network”… or why the doctors I saw appeared in the insurance company’s website of providers… or why they sent me two letters assuring me that my treatments “meet criteria and have been certified”… or why they waited five long, costly months to tell me that my doctors were not “in network.”

Bottom Line: They won’t pay. Period. So don’t ask.

<snip>

More: http://www.thedailybeast.com/articles/2014/11/24/how-the-health-care-bureaucracy-killed-me.html#

[Faux pas]

1. Very sad

RIP Malcolm MacDougall

[pnwmom]

2. It wasn't the ACA that killed him. At his age AND with that condition, he was dying anyway.

Maybe instead of putting him through that Kafka-like hell, they should have just admitted what was probably really behind this:

that an 85 year old with stage 4 cancer (metastasized to his liver and bones, including his spine) probably should have been in hospice, because he most likely would have died soon no matter what expensive tests and procedures he was put through.

[SheilaT]

6. Often people in hospice live a bit longer

simply because aggressive intervention is stopped, and the person is made comfortable and as pain free as possible. That might not have happened in this particular case, but still, hospice is a wonderful thing.

[BrotherIvan]

7. His doctors recommended these tests and treatments

It should not be up to an insurance company to decide care over your doctor. He had PAID his premiums, the deal is supposed to be that he is now covered in the event of an illness. The insurance company basically waited for him to die so they didn't have to pay. And you're defending that??

[pnwmom]

12. Doctors are loathe to give up no matter what,

even though people tend to last longer, and more comfortably, in hospice.

And with Medicare we have the same problem -- does it make sense, as a society, to pay so much in the last months of an elderly, terminally ill patient in the hope of extending their lives for a few days, weeks, or months? When we don't spend enough to make sure all babies and children are well fed?

[Mz Pip]

31. I agree

I remember all the fuss about end of life conversations that were covered through the ACA. Death Panels they were called by those who opposed the ACA.

I believe people need to be able to have that conversation with their doctor and learn what their options are and not be given unrealistic hope because the doctor is afraid of getting sued by the family who is in denial.

We don't deal with death very realistically in this culture.

[truedelphi]

54. Oh for Pete's sake - his age was incidental as they deny deny deny whatever

Your damn age happens to be.

A ten yr old needs a special treatment to save his leg, and the Big Insurers will deny it to save themselves money.

I myself had jaw surgery the summer of 2009. I went jumping through all applicable hoops to get the surgery, and since the Big Insurer, Friggin POS Anthem, said I had to pay upfront and they would re-imburse afterwards, that is what I did.

Then they told me that I couldn't submit paperwork that had to be sent in with the claim. Only the doctors could submit the paperwork with claim forms. Then they told the surgeons that they weren't suppsoed to do anything; I was. But of course, they told me it was the doctors, and since no one ever sent me claim forms, how could I submit anything.

I did try and fight with them, but gave up, largely because during that month I was in pain from the surgery. (Try talking to people after you have had a jaw operation.)


In the end, I ended not getting re-imbursed. And yet Anthem is one of three Big Insurers that is offered to me, like shit on a shingle, to choose from in terms of the Calif exchange.

If Bush had had Rahm Emanuel and Liz Fowler write this piece of shit bogus Act, the Democrat loyalists here would be up in arms. But because it is their special savior, the Big Corporations' favorite spokesperson, they refuse to admit that reform that doesn't actually reform is nothing more than an enabling of the parasites.

[pnwmom]

61. His age combined with his diagnosis of stage 4 cancer is anything but incidental.

85 year olds have much more difficulty tolerating many cancer treatments than younger people.

And at his age, if he was concerned about getting access to every doctor and every treatment, then the logical choice would have been single-payer Medicare, not some private "Medicare Advantage" plan.

If you are eligible for Medicare, stay away from Medicare Advantage. Those plans have been proven to be more expensive while not offering any real advantages in outcomes.

[elehhhhna]

55. if hes 85 Isnt he on medicare anyway?

[jeff47]

57. Nope.

You have to sign up, and you have to not sign up for Medicare Advantage.

[pnwmom]

62. He should -- but he must have opted for the private version, "Medicare Advantage"

instead of the single-payer government-run Medicare most people choose.

So it's not fair for him to blame Obamacare or for the Daily Beast not to clarify this point.

[former9thward]

86. Medicare is not remotely single payer.

Medicare is a jumble of payments to the government, payments to doctors, payments to hospitals, payments to insurance supplements, and payments to pharmacies.

[pnwmom]

87. Your definition isn't remotely the definition of "single-payer."

Single-payer means there is only a single-payer -- the government -- not that there is only a single health care PROVIDER. (Under Medicare, a single-payer makes payments to multiple providers, including ANY physician or hospital that participates in Medicare -- which includes the overwhelming majority.)

A multiple-payer system is what we have now -- multiple insurance companies, private and public, that pay providers.

[former9thward]

88. No what we have now is people on Medicare making payments

to multiple entities. With everyone blaming everyone else for the costs.

[pnwmom]

89. You still don't understand because you're confusing PAYER with PAYEE.

Medicare has a single PAYER (the government)-- paying multiple PAYEES (health care providers.)

Yes, Medicare makes payments to multiple providers, just as the Canadian single-payer system does in Canada.

From Wikipedia's article on single payer:

http://en.wikipedia.org/wiki/Single-payer_health_care

Medicare in the United States is a single-payer healthcare system, but is restricted to only senior citizens over the age of 65, people under 65 who have specific disabilities, and anyone with End-Stage Renal Disease.

[former9thward]

91. The problem is that people on Medicare

have to make multiple payments. Not just one payment to Medicare but to everyone else too depending on charges and deductibles. That is wrong. Medicare should pay it all and be done with it.

[pnwmom]

92. Well, single-payer won't solve that problem.

There may be systems in other countries that would work like that, but single-payer itself doesn't mean that people never see bills.

[Dorian Gray]

16. It's mind boggling

that someone would defend that.

[pnwmom]

35. It's mind boggling to me that you think it's okay to blame Obamacare,

when he had chosen a private Medicare advantage plan over Medicare single-payer. If he had gone with standard Medicare none of this would have happened.

[BrotherIvan]

59. Obamacare isn't Medicare

You're trying to defend "Obamacare," which is actually private health insurance, but then saying "he should have been signed up for Medicare because they would pay for it." The truth is, his private insurance didn't, which is governed by "Obamacare." So which is it? Do you even know?

[pnwmom]

63. His private "Medicare Advantage" plan is NOT governed by the ACA.

It is regulated by a law that went into effect years earlier.

He made the wrong decision (rejecting single-payer Medicare) if he wanted to have free choice of doctors and treatments, but it's not right to blame this on Obamacare.

http://kff.org/medicare/report/what-do-we-know-about-health-care-access-and-quality-in-medicare-advantage-versus-the-traditional-medicare-program/

Despite great interest in comparisons between traditional Medicare and Medicare Advantage, studies comparing overall quality and access to care between Medicare Advantage plans and traditional Medicare tend to be based on relatively old data, and a limited set of measures.

On the one hand, the evidence indicates that Medicare HMOs tend to perform better than traditional Medicare in providing preventive services and using resources more conservatively, at least through 2009. These are metrics where HMOs have historically been strong. On the other hand, beneficiaries continue to rate traditional Medicare more favorably than Medicare Advantage plans in terms of quality and access, such as overall care and plan rating, though one study suggests that the difference may be narrowing between traditional Medicare and Medicare Advantage for the average beneficiary. Among beneficiaries who are sick, the differential between traditional Medicare and Medicare Advantage is particularly large (relative to those who are healthy), favoring traditional Medicare. Very few studies include evidence based on all types of Medicare Advantage plans, including analysis of performance for newer models, such as local and regional PPOs whose enrollment is growing.

As the beneficiary population ages, better evidence is needed on how Medicare Advantage plans perform relative to traditional Medicare for patients with significant medical needs that make them particularly vulnerable to poorer care. The ability to assess quality and access for such subgroups is limited because many data sources do not allow subgroups to be identified or have too small a sample size to support estimates. Also, in many cases, metrics employed may not be specific to the particular needs or the way a patient’s overall health and functional status or other comorbid conditions influence the care they receive.

[Dorian Gray]

68. I didn't say anything about Obamacare

I think it's criminal that insurance companies don't pay claims. Period.

[LondonReign2]

83. It's her job

[eggplant]

18. +1

I understood what you said. Suggesting hospice is not the same as defending the insurance company's behavior. Not even close. The people who are claiming that was your point are way off base.

[Nuclear Unicorn]

20. Here's a weird thought --

Maybe the guy who paid in all the money to a health policy for the day he might get sick should be the one who decides if he gets treated.

...he most likely would have died soon no matter what expensive tests and procedures he was put through.

That should be his choice not some faceless group deciding who lives and who dies based on their value of a human life. And if some third party can decide to withhold treatment then he should be allowed to not pay for a policy.

[pnwmom]

32. He was an 85 yr. old on Medicare so this has nothing at all to do with Obamacare.

His insurance was the "single payer" insurance everyone seems to want.

[Nuclear Unicorn]

36. What's his age got to do with anything? Either he has paid ito the coverage pool or he

hasn't. If he has then he should be making his healthcare decisions, not statisticians.

[pnwmom]

37. His age means he was eligible for Medicare. Standard Medicare pays the bills,

without regard to what network you're in.

He must have chosen a private insurer's "Medicare Advantage" plan -- instead of single-payer Medicare. So this has nothing to do with the ACA, but with the Medicare Advantage program that was started years before.

But I also think that doctors and the hospital industry are complicit in encouraging too many dying people to subject themselves to unnecessary medical procedures at the end of life.

[WillyT]

64. Wow... So Just Let 'Em Die ???

"But I also think that doctors and the hospital industry are complicit in encouraging too many dying people to subject themselves to unnecessary medical procedures at the end of life."

Really ???

[pnwmom]

65. Hospice provides palliative care, which I strongly prefer to

"just torture them with painful, unnecessary -- but profitable -- treatments till they die."

[WillyT]

67. It's Still The DOCTOR'S Call !!!

And the longer the insurance companies wait and delay, the surer the death sentence becomes.

My 85 year old mom just had her gall bladder removed, which was gangrenous and pus-filled. If she had had these delays, she would have died of sepsis.

I understand that that he had Medicare advantage... apparently he thought it was to his Advantage to have it. Sadly he was duped.

Single Payer... No Exceptions !!!

[Ms. Toad]

74. Medicare does not necessarily mean single payer.

You can get better coverage on Medicare Advantage (farmed out to insurance companies which offer standard insurance plans) - and since he is naming a specific company that is probably what he has.

Of course, for this particular scenario it probably would have worked out better to just have the standard single payer.

[pnwmom]

78. Medicare Advantage isn't really Medicare. As you say, it's the private insurance

the government will let you substitute for single-payer, government-run Medicare.

And it's not better. Research has shown that though it does cost the government more, it doesn't provide better outcomes. And that's the bottom line.

[Ms. Toad]

79. My point is that just because he is 85 doesn't mean he is on single payer.

That was the connection you were making. I was merely pointing out that his statements about being "in network" mean he is almost certainly on Medicare Advantage, rather than Medicare.

Given how well I know the insurance regime, I might well choose Medicare Advantage when the time comes. Often - if you stay in network - it covers a larger portion of your care. So from my personal perspective - of only voluntarily gone out of network for a psychologist for my daughter in the geographic fringes of the network in 35 years of insurance coverage, and of having several experimental treatments approved by multiple insurance companies, it is likely to be a better deal for me personally. That doesn't mean it is a better deal for the average consumer, or for the government.

But - bottom line - he almost certainly is not on the single payer system, given what he said about in/out of network costs.

[pnwmom]

81. But this has nothing to do with Obamacare, as he implies.

It has to do with the private insurance he voluntarily chose.

[Ms. Toad]

85. This is what I was responding to:

His insurance was the "single payer" insurance everyone seems to want.

It wasn't, since he seems to have opted into Medicare Advantage.

I agree it has nothing to do with the Affordable Care Act - but it also has nothing to do with single payer.

[Silent3]

47. I'll remember to always demand a new car from my car insurance company after any fender bender...

...because, after all, I paid into the system, so how I get covered should be my choice, right? I don't want some "faceless group" deciding for me that replacing a few bits and pieces of my car is good enough. Dammit, I want a new one!

Yes, health insurance is about something much more vital than a car, but the principles are the same.

A large group pays into the system (be it via taxation for government coverage, or premiums for private coverage), a not-unlimited pool of funds is created for paying claims, and then some sort of administrative decision by someone put in charge by some process has to decide which claims are honored, and with how much money.

Clearly no insurance system can work simply by letting each claimant get whatever they ask for out of the system, no questions asked, no standards having to be met.

[Nuclear Unicorn]

51. Sounds death-panelly

[Silent3]

73. There isn't a single medical system in the world that isn't a bit "death panelly"

No one anywhere under any system has the unlimited resources to do everything conceivably possibly to cure every malady and save every life. There are always winners and losers.

Transplant organs are a clear example of a limited capability to supply patient needs. The resource of money isn't even the biggest limiting factor -- in this case, there simply aren't enough available organs to go around. Somebody is going to lose out.

Would letting patients and their doctors alone decide what treatment the patient should get, no nasty bureaucrats and callous administrators allowed, somehow magically eliminate the organ shortages?

[Nuclear Unicorn]

93. Appealing to the error of others is not justification for committing new errors.

As for the shortage of donor organs I hope you aren't suggesting some need to be relegated to no treatment so they can be harvested for others. That would be an even bigger error.

[Silent3]

94. Where did I say anything about "the error of others"?

That health care resources are limited, including viable and matching donor organs, is not an error -- it's reality.

[Nuclear Unicorn]

96. The scarcity, as far as the OP is concerned, is artificial and bureaucratic. nt

[pnwmom]

98. There isn't an unlimited amount of funds available for healthcare in any system. n/t

[Silent3]

99. Maybe some scarcity, not anywhere near all of it.

This little subthread is about more than just the limited case of the OP, it's about your very broad proposition that "Maybe the guy who paid in all the money to a health policy for the day he might get sick should be the one who decides if he gets treated."

There are certainly limited cases where that makes sense, but as a broad policy I would hope you can see how that's clearly unfeasible. In the big picture, there will always need to be some kind of administrative or bureaucratic involvement.

You can argue over the quality and the fairness of that administration -- indeed, you must -- but only with unrealistic blinders on can you argue against its very existence.

[pnwmom]

97. Science should be used to determine which people have the greatest likelihood

of benefiting -- in terms of extended life -- from a transplant, since there is a very limited supply.

This would not apply to a directed donation, however.

[Nuclear Unicorn]

101. Eugenics sucks. nt

[HERVEPA]

103. You might want to look up what eugenics is before you post incorrectly about it.

[pnwmom]

105. This has nothing to do with eugenics. Hint:

the word is based on the same word that "genes" is based on. Eugenics was about controlling breeding for the sake of improving the race.

It has nothing to do with reserving a rare or extremely costly treatment for those who are most likely to actually benefit from it.

[rhett o rick]

72. Doctors often call for tests, not because they will extend your life or

even make you more comfortable, but because of possible liabilities. In some ways insurance coverage is zero-sum. The decision of the pool (insurers) is where to best utilize the financial resources of the pool. Deciding on how best to use our medical resources can be described as "death panelly", but it happens every day. The choice of who gets a new heart includes a lot of factors. We don't give everyone a new heart.

I personally know of a case where a lady over 70 was found to have cancer in most of her major organs including brain. Two days before her death the doctors were discussing chemo-therapy. Who should make this decision?

[JEB]

76. Think how much money could be saved if they stated at age 50.

Less agony too.

[moriah]

95. He said "despite Obamacare", not *because* of it.

Still, just like euthanasia, it should be a CHOICE to go into hospice or keep fighting advanced cancer. Insurance companies shouldn't refuse treatment and push palliative care, no matter how hopeless the individual case may seem, if the patient still wants to fight.

That's taking medical decisions out of the realm of doctors and patients. And since I believe that my medical care is between my doctor and me, no matter what, I'm not about to say that others shouldn't make their decisions about life and death with their doctors, instead of approving medical treatments being overruled by their insurance companies.

[Fumesucker]

3. The 99% are a natural resource to be exploited; mined, processed, packaged, sold and consumed

[BrotherIvan]

4. And so the dance on this thread begins

We pay for health insurance and then the insurers deny payment. They are, in fact, breaking the contract by trying to exploit every possible loophole--loopholes that were not fixed by the ACA.

So now, the cheerleader answer is to shut up and die, for your family to go bankrupt, for you to be denied care that your doctor deems necessary because money is more important.

I went through cancer with my mother. She was never denied anything, nor did they try any shenanigans about paying. It was one thing I did not worry about. I can't imagine fighting the insurance company while my family member was ill. Saying, oh well, we got a win so just shut up while people are suffering at the hands of predatory companies sounds a hell of a lot like Republicans.

[Maedhros]

14. The ACA's best achievement is that it made sure that more uninsured people

are covered by insurance.

However, it does not appear that the ACA addresses the bigger problem: health care is still too expensive for ordinary Americans to afford. Insurance coverage alone will not solve the problem if the coverage is inadequate and riddled with loopholes.

[BrotherIvan]

29. The Medicaid expansion was the best part

Unfortunately there were loopholes that allowed red states to deny it. But everyone who is now covered under ACA policies will shortly find out how worthless they actually are. I already have.

[Maedhros]

38. The real test will be whether the ACA reduces medical bankruptcies.

I suspect not.

[jeff47]

22. He was 86. Medicare should have paid for everything.

Instead, it appears he chose a Medicare Advantage plan instead of traditional Medicare.

The article doesn't explicitly say, but that's what would make the most sense. A supplemental plan wouldn't have refused to cover treatment, it would have refused to pay it's 20% on part B.

[BrotherIvan]

24. True, Medicare would have been better

But what it points out is that Medicare would be better for all of us.

[jeff47]

25. Yes, it would. But sometimes you gotta climb a hill before you climb a mountain. (nt)

[BrotherIvan]

27. Ok

But if we all sit here (and shut up) and say the situation we have now is at all tenable, then we don't move toward Medicare for All. Republicans won't do it, only liberals will. The ACA cheerleading has neutered the push for what we really need: Medicare for All. We still have to dance with these evil insurance companies and people are being denied care.

[jeff47]

30. Then you don't shut up. You yell at the right people.

The ACA moves the fight to the states. Yelling at the feds isn't gonna help for the time being.

If you're in a blue state, start pressuring your state to offer a public option or single-payer on its exchange. You'll become an example when we return to the national battle.

If you're in a red state, keep pressuring your state to expand Medicaid and fully implement the ACA.

These battles are never "done". We're still tweaking Social Security and Medicare, despite them being more than 50 years old.

[jeff47]

104. Reading. Try it.

If you had, you might have noticed I explicitly said they need to work on their state government.

[jwirr]

5. Did he have one of those policies that "they liked and wanted to keep"? In other words did his

insurance come from ACA?

[BrotherIvan]

8. You do know that the ACA is not an insurance company right?

[jwirr]

10. Of course but they set up a market with policies that fit their criteria. When this first started

there were a whole bunch of people screaming about losing their old policies (inferior ones) so the president let them keep theirs. My question is this man's policy one of those inferior ones or does he have a policy for the market set up through either the states or the Feds?

I am working with a woman right now who has one of them and she is just now realizing that they stink. Luckily for her it is open enrollment time. She can do now what she should have done in the first place.

Also why is he not on Medicare? They paid my mother's entire cancer treatment bill.

[pnwmom]

13. I wondered that, too. Obamacare doesn't cover every policy. n/t

[Fla Dem]

15. He was 85 years old. He should have been on Medicare. ACA is for those under 65 years old.

If he was on medicare and I don't know why he would not have been, he may have been paying for a medicare advantage policy, which is supposed to enhance the coverage you get under medicare. Although I find my medicare advantage coverage is at times less than the coverage under just medicare, but because I elected to take out the additional insurance, that's the one I have to go with.

[ctaylors6]

17. I also wondered about the Medicare

I searched for the plan it said he was on, and it looks like it's a New York state exchange plan. But why would he get that if he's over 65?

[jwirr]

50. Part of a pension?

[csziggy]

100. If he were self employeed and didn't pay into Medicare, going through an ACA

Exchange might have been cheaper?

I've never paid into Medicare or Social Security. Once my husband is eligible for Medicare I might be able to get in under his coverage - but I might not. It's still not clear to me. Even if I can be covered under his Medicare, it might be cheaper for me to remain on a subsidized policy through the HealthCare.gov exchange. It certainly looks as though our income will remain low enough for us to get significant subsidies through the exchange. That is, unless the Supreme Court eliminates that option since we live in Florida which did not set up its own exchange.

I'm not sure what this writer's circumstances might have been. Maybe he always worked as a freelance journalist and never paid into the social safety net so going through the steps for coverage under the ACA may have been cheaper for him.

[jeff47]

21. It sounds like he had a Medicare Advantage plan.

Which completely replaces traditional Medicare.

"Enhancing" the coverage under Medicare is a Medicare supplement, not Medicare Advantage. Medicare supplements cover part B and part D expenses that aren't covered by the government (Gov't pays 80% of part B. Part D is drug coverage). Medicare supplements can't be worse than basic Medicare - they can't make you pay more than 20% for part B costs, for example.

[dilby]

9. That is really sad but it's insurance not healthcare.

Me Personally if I am 85 and have stage 4 cancer I am going to start shooting heroin, smoke crack, snort coke all the bad shit I never did in life and then just opt for the Oregon Death with Dignity.

[jwirr]

11. LOL good plan.

[LiberalArkie]

23. Yep, a bottle of hydrocodone a bottle of valium, and a liter of the good Crown.

And I might start smoking again before I take the meds. Any other advice? I have no plans of struggling to live if I get a diagnosis of something bad. Maybe a little LSD with the other meds? I would like to leave with a smile on my face and not in a damn hospital or nursing home.

[WinkyDink]

82. Don't be daft. Take it from me: A hospice setting eases one out, if you know what I mean.

Kind of like your plan, without the hang-over. And the staff, not your family, cleans up.

[LiberalArkie]

84. Single, no family, no kids. Just a dog and cats.

[bravenak]

28. Me too.

I have though that over and decided that I'll save my bad stuff fo when I'm already dying.

[jeff47]

19. He was 86. "Obamacare" isn't the issue.

An 86-year-old can get Medicare. Why was he dealing with a private insurance company?

It doesn't explicitly say in the article, but it sounds like he enrolled in a "Medicare Advantage" plan - the private insurance that was introduced to compete with "traditional" Medicare. For example, he talked about the problem of paying for his time in the hospital, but that's Medicare part A - 100% covered by the government, if he had "traditional" Medicare.

Medicare Advantage plans suck. And this article is an example of why they suck.

Anyway, the only reforms that were relevant from the ACA was the reduced reimbursement rate for Medicare Advantage plans - they've always cost the government more than traditional Medicare. Those reduced reimbursements may have caused his greedy bastards ....er... insurance company to try and avoid paying his bills. But the ACA didn't require him to get private insurance. Nor did it significantly change coverage.

[B Calm]

26. BINGO! I knew there

had to be another side to this story!

[pnwmom]

33. And "Medicare Advantage" was put into place well before the ACA, and subsequent

research shows it doesn't improve health and costs more.

The Republicans who pushed it were counting on the open market to solve Medicare's financial woes, and it didn't help at all.

[nichomachus]

40. No, you don't understand Medicare -- it doesn't pay 100 percent

It pays 80 percent. If you are on Medicare, you have three choices.

You can just go with traditional Medicare, which pays 80 percent of your medical costs. You are responsible for the rest. So, you are self insuring. If the cost is $100,000, Medicare pays $80,000 and you owe $20,000.

If you don't want to do that, you have two choices

1. You can get a supplement plan from a private insurer and that will cover the rest. Those plans start at about $200 or so a month and cna go considerably higher -- with a $500 deductible.

2. You can join a Medicare Advantage plan, which is basically an HMO. The government gives the HMO a certain amount of money a month for you. The HMO makes money by denying you care. It's a really good plan -- until and unless you get sick.

So your choices are to self insure or deal with the insurance corporations.

[jeff47]

41. You're talking about Medicare Part B.

Medicare has multiple parts.

Medicare Part A covers inpatient hospital bills. The government pays 100% of those bills.
Medicare Part B covers doctor's office visits. The government pays 80% of those bills.
Medicare Part C is Medicare Advantage. This is private insurance that replaces both part A and B.
Medicare Part D is drug coverage.

You're talking about Medicare Part B. Medicare Part A still covers inpatient hospital bills at 100%.

Supplemental insurance to cover Part B expenses is usually much lower than you claim, but rates can vary based on history and location.

[nichomachus]

43. Not quite

For hospital stays, first you pay a deductible of $1,216. Then, for the first 60 days, Medicare pays 100 percent. After that, you're on the hook for $315 a day, until Day 90, when it goes up to $630 a day out of your pocket.

But $630 a day here and $630 a day there, pretty soon it adds up - especially if your monthly SS check is $1,200.

[jeff47]

44. It's nice you finally googled the program, and found that your $20,000 bill is now $1200. (nt)

[nichomachus]

46. Thanks for the unwarranted snark

But you're still spreading disinformation about Medicare. Many people join Medicare advantage plans because they don't want to risk self-insuring and they can't afford to buy supplemental plans.

[jeff47]

56. The snark is because of your large errors.

Plus your entry into the subthread with fearmongering via massively misstating how traditional Medicare works.

You are claiming that a program that pays 100% of the medical bills (Medicare Advantage) is cheaper than a program that pays 20% of office visits and virtually nothing for inpatient (Medicare + supplement).

And I'm well aware that you are wrong for the cost of supplemental plans. By about a factor of 10 in my area for a nonsmoker.

You are steering people towards the exact same program that this OP decries.

[pnwmom]

34. This 85 yr. old CHOSE a private plan instead of single-payer Medicare. He made the wrong choice,

but it's not the fault of Obamacare.

This just shows why Medicare Advantage plans proved to be crap.

[nichomachus]

39. I don't know what you mean by this.

What wrong choice did he make?

[DURHAM D]

42. Exactly.

The article would have been great if it had explained that he made a stupid decision in the first place or perhaps his former employer just enrolled him and he doesn't understand the difference between regular Medicare and Medicare Advantage.

Most people that were enrolled by their former employer don't have a clue... my brother and two of my cousins for example. My brother's former employer (AT & T) is changing the benefits for their legacies in 2015 and I have spent hours on the phone helping him understand the difference between regular and Advantage and discussing drug and dental coverage. He even called me from his face to face meeting with them and put me on speaker phone so I could explain to them the difference. One thing he wanted me to stress to them is why they can't blame it on "Obamacare".

[nichomachus]

45. "Regular Medicare" does not pay all your medical costs.

You need either supplemental insurance, which you get from an insurance corporation -- and which can be expensive -- or you need to go into a Medicare Advantage plan, which is cheaper, but is still an HMO.

I don't know why you're saying this man made a "stupid decision." His choices were to self-insure, which probably wasn't feasible for him, buy a supplemental plan, which could run to $3,000 a year or more, or join a Medicare advantage plan.

[DURHAM D]

49. Where did I state that regular medicare pays all medical costs?

I didn't.

It has been my experience that the large majority of folks over 65 who are receiving benefits from their former employers have little knowledge about medicare vs. medicare advantage. In fact, people on advantage programs will argue until the cows come home they are on regular medicare when I know they are not. One hint is the way they talk about their drug coverage.

As for that $3K figure... are you talking about two people? My Supplemental/Medigap Plan F is half that amount but it depends on exactly how old you are and what state you live in.

[Hoyt]

48. 30% of Medicare beneficiaries have made the Medicare Advantage choice, mostly to save money. Plus,

I think there is more to this story than what is written.

I cannot find where Health Republic offers a Medicare Advantage Plan, so that does not appear to be an issue.

Further, Health Republic appears to be a non-profit plan. According to their web-sit, Health Republic Insurance of New York is a not-for-profit health insurance CO-OP (Consumer Operated and Oriented Plan).

I doubt the patient -- 85 years old -- was covered by anything but Medicare, possibly a supplement, and maybe Medicaid.

As to Medicare Advantage Plans, personally I want a plan with the lowest premiums possible -- that means that the plan doesn't do every darn thing that a doctor orders, especially if they profit from it and it is of questionable medical value.

[jeff47]

60. Except Medicare wouldn't block a doctor's order.

ETA: block a doctor's order because he's out-of-network. There is no network.

And a supplement would refuse to pay the 20% on their part B coverage, not block the procedure. So a supplement doesn't make sense with the rest of the story.

As to Medicare Advantage Plans, personally I want a plan with the lowest premiums possible -- that means that the plan doesn't do every darn thing that a doctor orders, especially if they profit from it and it is of questionable medical value.

And if you're an unlucky 86 year old in the OP, it has the benefit of killing you.

Advantage plans usually suck in people with low premiums at 65, and having the premiums shoot up from there.

[Hoyt]

66. If they go too high, you move to a more competitive plan or traditional Medicare with

a supplement.

In any event, something ain't right about the story.

[hollysmom]

52. When I had cancer, (ha ha , good title)

The insurance company and doctor were locked in a fight, the insurance wanted me to have 2 hour surgery and then go home as an out patient. The doctor wanted me in the hospital over night. They fought all day, finally the doctor gave up at 4 PM instead of sending me home, she though late operation, late recovery I would probably be in the hospital over night, unfortunately it lead to bad practices by the anesthesiologist who did not come see me before the operation as I request, gave me a fast shot way too strong, so I thought my arm would explode and when I cried out shoved a mask on my face while I was crying and alert and had he nurses hold me down while I struggled to breathe. I didn't sue him, but I should have as I woke up and had a series of asthma attacks so was in the hospital all night, and if I was not on oxygen, I don't know what would have happened, not to mention that these attacks caused my glued stitches to open up and they had to glue them again. Bloody mess. but all this is leading up to, if the insurance wasn't going to pay, I had taken the 25K out of my 401K and was ready to use that to pay for the operation. The hospital would not let you walk in the door unless you have paid your portion of the operation up front.

Oddly enough I did get billed for the operation but found out it had already been paid by insurance. I worked for insurance for about 1/3 of my career and had to deal with these people as co-workers - ugh. Yeah, those words he heard are from scripts. But oddly enough they are used even when you are trying to return money to them. I once was covered by my job and covered by my husbands plan, I ended up in some sort of payment loop where I was getting paid over and over. I was working at the insurance company at that time, so I walked in, told them they had a bug and needed to fix it, and here is how they could do it. I have to argue about this up to the president, and he told me that I should just spend the money because they are so far in debt this little money would not help them. I told them it was a 2 day fix, I found the program, I found the bug, It was not my department but I could step in for a few days and it would save them over 1 million a year - they just were not interested! They said they were rewriting the system and it would be fixed them, - that system never worked, and never went into service, so they did not fix it for at least another 5 years. I lost track after that, but after you have talked to the president of the company - where do you go? I gave up.

My point with insurance, it is not just deliberately trying to screw you, it is also just idiocy that prevails in the business. People don't want to use their brains.

[Erich Bloodaxe BSN]

53. Yet another reason why we need universal healthcare, not 'insurance'. nt

[WillyT]

58. Yep... The 'Death Panels' Are The Insurance Companies...

To hell with them.

[SomethingFishy]

69. Beat me to it..

[WillyT]

70. :)

[LiberalElite]

71. I never heard of Malcolm MacDougall so I Googled him -

http://en.wikipedia.org/wiki/Mal_MacDougall

Note the second paragraph - Yeah I know it's not nice to speak ill of the dead.... BUT
Perhaps he had an agenda?

[hobbit709]

75. In 2001 I had a goround with NYLCare.

It took 5 months for them to approve the surgery recommended by 4 different specialists. It was only after I sent them a letter stating that I was going to hire an attorney and marked the letter cc: my attorney and the TX State Insurance Commission that 3 days after I mailed it the surgeon called me and said "Are you ready for surgery on Thursday?"

[Zorra]

77. It's not unusual for private health insurance companies to kill people for profit.

They've been doing it for decades.

[Ms. Toad]

80. As several others have pointed out,

His death had nothing to do with the Affordable Care Act. The changes to Medicare were minimal, and did not force him into the Medicare Advantage option it appears he chose. It was the insurance company he elected under the Medicare Advantage option (around long before the ACA) that hit him with additional charges and treatment denials.

[closeupready]

90. The nurse should be prosecuted for practicing medicine without an M.D.

but for whatever reason, breaking that law is never prosecuted.