Florida Health Insurance Topic:
"Rx (Drug) Coverage"

Health Insurance (Rx)

The following is a health insurance story, from real people, like you.

Many years ago when I was in the Marine Corps, I knew a gunnery sergeant who liked to say, "We operate on the KISS system Keep it simple, Stupid."

Congress should keep that system in mind when it works on health care reform.

Consider the case of Gregg Neely, who was the subject of Sunday's column. He is a 42-year-old accountant, and the father of three. His wife, Stacy, is also a professional. She works in Human Resources for the Rockwood School District.

In October of 2006, Gregg was diagnosed with amyotrophic lateral sclerosis, better known as Lou Gehrig's disease. He started having trouble swallowing and eating and he began to lose weight. In March of this year, he contracted pneumonia and spent 16 days in the hospital. While in the hospital, doctors installed a feeding tube. His health insurance paid for the hospital stay and the installation of the feeding tube, but then refused to pay for the formulated food that goes into the feeding tube.

Gregg was fortunate to have a pulmonologist who cared. Dr. Neil Ettinger spoke to the medical director of the insurance company, and then to an appeals committee. He made two arguments. First, tube feedings were necessary. They were not optional. Second, it was less expensive for the insurance company to allow Gregg to remain in his home, where his care was provided by his wife, than to have him go to a nursing home. Less expensive for the insurance company and better for the patient.

Still, the insurance company denied the appeal. Last week, the insurance company reconsidered and decided to pay for the foodstuff and the supplies. The case made me think about the debate over health care reform.

Buried deep in Gregg's policy in Section 8, Item 27 was an exclusion for outpatient tube feedings or formula.

Who reads their policies? Nobody. The cover page of Gregg's policy says the document is 162 pages long. Even if a person did read it, what good would it do? Most of us don't understand the language. "The cost of outpatient enteral tube feedings or formula and supplies except when used for Phenylketonuria (PKU) or any other amino and organic acid inherited disease is not Covered, except as defined as a Covered Service."

What health care reform should be about is simplifying things. If you have insurance and you get sick, your care will be provided. Period. Of course, there will be levels of care. If you have a gold-plated policy, maybe you get a private room. Maybe you can go to any doctor. If you need a wheelchair, maybe you get a new one. Perhaps a cheaper policy will require you to share a hospital room. Maybe you have to go a doctor who is "in-network." Maybe your wheelchair will be of the used variety. But still, you're covered. You need tube feedings to live, you get the food for those feedings.

I would argue that a health insurance policy ought to be no longer than five pages.

It's like tax reform. The first step in tax reform ought to be simplifying the tax code. Right now, it is thousands and thousands of pages, and most people figure that all of those pages were put there to benefit somebody. That's why some type of flat tax sounds so attractive to so many of us.

When Congress talks about health care reform, they ought to keep in mind Gregg and Stacy Neely, two well educated people with jobs and health insurance. They were as prepared as anybody can be for this kind of disaster.

And what happened? In the midst of trying to deal with a horrific disease, they had to fight the insurance company. Stacy had to go in front of a committee and plead for something as basic as food for a feeding tube. That's ridiculous.

A basic health insurance policy might well exclude certain kinds of therapies, or elective surgeries, or experimental procedures. But if you have the misfortune to contract some kind of dreaded disease, you ought to have the peace of mind of knowing that you will get the necessary treatment. After all, you have health insurance.

So that's the first thing I'd tell Congress. We want to simplify things. We want to know that if we have health insurance and we get sick, we'll get care.

Unfortunately, I am not sure Congress understands simplicity. I read that the final health care reform bill will probably be about 1,000 pages. In other words, it will be like our health insurance policies unread and unreadable.

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