California Insurance Lawyer Blog

In U.S.A Today this week, elder-care author Howard Gleckman illuminates one of the most important but least discussed issues in the national debate about health care reform: What are we doing to help the elderly and disabled who don’t need acute hospital care but rather personal assistance in their homes. See, “What About Long-Term Care,” May 26, 2009,

Gleckman says Congress is ignoring its chance to change the way our country delivers long-term care ("LTC"), now mostly through Medicare that pays for nursing home treatment which costs thousands more a year than in-home care. Nursing home care could amount to as much as $75,000 a year; a home health aide is paid $20 an hour.

“Congress and President Obama could create a system of universal long-term care insurance, built on a combination of public and private coverage,” writes Gleckman. “They could end the reliance of millions on the welfare-like Medicaid system while reducing the tremendous pressure that program is putting on both state and federal budgets. And, they could further shift the focus of long-term assistance to community care instead of nursing facilities.”

But, concludes Gleckman, long-term care reform is unlikely to happen even though Sen. Edward Kennedy and Rep. Frank Pallone have proposed government-provided LTC insurance that could cost as little as $100 a month.

So where does that leave us? If you are among the seven million Americans who can afford private LTC coverage, you are in good shape to preserve your assets and savings as you age or become disabled. For the rest, this is another wake-up call. Any health reform the federal government is likely to approve won’t be much help for the elderly and disabled. Medicare won’t pay for home health aid, and Medicaid only covers some costs after the patient is impoverished.

Why isn’t the federal government creating a more comprehensive plan? Most likely because it is not getting much help from the most important stakeholder when it comes to the economics of health care, the insurance industry. That industry doesn’t want to take care of the sick, the elderly and the disabled. Rather, insurers are in the business of making money for shareholders. By issuing policies to healthy people then trying to find ways to deny coverage when they get ill, profits can be enhanced. And because they have been getting away with these practices for years means they have no incentive to devise a revolutionary public-private partnership that would provide affordable health care to Americans from the cradle to the grave.

Gleckman calls it a tragedy. What do you think?

Los Angeles Times business columnist David Lazarus is about as skeptical as we are about the insurance industry’s pronouncement that it is ready to work with the Obama administration to overhaul the nation’s healthcare system. “Insurers Return to the Table Again,” (May 17, 2009). Lazarus asks the question, “Does anybody trust them?” He couldn’t find anyone who said “yes.”

Lazarus compares this round of the industry’s enthusiasm to “serve the national best interests” to the 1970s when the Carter administration attempted to craft a national healthcare policy. “Nothing came of it,” said Alain Enthoven, who was a Carter consultant. “The whole thing was just a joke.” It happened in the 1990s during the Clinton administration. “They said they wanted to be at the table and wanted to deal,” former Clinton health official Karen Pollitz told Lazarus. “Then they all left. They saw that they could kill it.”

Insurance industry lobby America’s Health Insurance Plans’ Robert Zirkelbach told Lazarus “everything’s different this time.” But no one is buying it.

Here’s the industry’s compromise: If the government forces everyone to buy health insurance, the industry will quit denying sick people coverage and equalize premiums for men and women. And that’s if the Obama administration scuttles its plan for public insurance that would compete with the private sector.

And Lazarus’s point is this: This time, it’s not about what’s “politically feasible and financially palatable.” No, he says, this time it’s about the people who can’t afford health insurance but can’t afford not to have it. That, he concludes, is all of us.

We hope the Obama administration reaches the same conclusion and forces the insurance industry to keep their promises. But we’re still skeptical.

The National Fibromyalgia Association, sponsor of Fibromyalgia Awareness Day, is using its 2009 campaign to focus on the far-reaching effects of the chronic pain disorder, including the financial, social and emotional repercussions. For information about May 12 events, log on to www.fmaware.org.

With so many chronic illnesses and so many organizations seeking to find cures and provide support for people suffering from them, it’s easy to lose a sense of urgency about why we draw attention to a particular syndrome. Fibromyalgia is one condition, however, that could benefit from increased awareness.

Many people, unless they have the illness or know someone who has it, have never even heard of fibromyalgia. If they have, it’s usually in the context of being labeled a “non-disease” or “all in your head.” This belief results from a number of factors.

First, fibromyalgia is difficult to diagnose. NFA research shows that it takes from three to five years to diagnose the syndrome. This could mean that many doctors don’t take the illness seriously and are not pursuing options that could lead to a speedy diagnosis. Because no lab test definitely proves a patient suffers from fibromyalgia, the doctor must rely on the patient’s description of symptoms. Doctors then diagnose by elimination.

Second, fibromyalgia is controversial. Some physicians don’t acknowledge that it is a real illness because in most cases the cause of the symptoms is an enigma. Medical science is reluctant to accept conditions for which there is no apparent cause. http://www.health.com/health/condition-article/0,,20188874,00.html.

Third, fibromyalgia affects women more often than men, and no one knows why. Add that to the fact that women have not historically been primary wage earners. Conditions that keep women from paid employment often don’t get the same level of respect as those that affect both genders equally.

Finally, insurance companies put up a fight to pay disability benefits for people unable to work because of fibromyalgia. They embrace the theory that it is not an illness and welcome medical assessment to reinforce that concept. The American Pain Foundation, in an informal study, found numerous barriers to the effective treatment of fibromyalgia, most notably the fear of losing insurance coverage once the syndrome was documented.

We support the National Fibromyalgia Association and its efforts to raise awareness of such a misunderstood syndrome.

America’s Health Care Plan Agrees the Practice Should Be Eliminated

U.S. Senator John Kerry introduced a bill this week that would end the insurance company practice of charging women as much as 50 percent higher premiums then men, reports UPI - “Health Insurers Agree to End Gender Bias.” The move could affect as many as 5.7 million women who are not covered by employer-sponsored plans but purchase individual coverage.

“The disparity between women and men in the individual marketplace is just plain wrong, and it has to change,” said Sen. Kerry. Testifying for the industry, Karen Ignagni of America’s Health Insurance Plan agreed that the industry should eliminate the practice.

The Associated Press took a more cynical view of insurer acquiescence. “Health Insurers Offer to Lower Rates for Women,” http://www.latimes.com/features/health/la-fi-insure-women6-2009may06,0,1110808.story?track=rss/. “The industry is trying to head off creation of a government health plan,” the article reported, “that would compete with companies to enroll middle class workers and their families.” Insurers fear of a government plan would ruin their business, and the industry is doing everything it can to prevent a public system.

That means that insurers are doing an “about-face” on financial positions they have insisted for years are necessary to keep them solvent. Such positions include charging women age 19 to 55 higher premiums because they are “more likely then men to have higher healthcare costs due to childbearing, a proclivity toward certain chronic illnesses and more routine healthcare habits.” In March, the industry agreed to stop charging sick people higher rates if the federal government required all citizens to have health insurance.

Whether or not the federal government is able to pass a public healthcare agenda, healthcare reforms that benefit women and the disabled are long overdue. Insurers subject illnesses that predominately affect women, such as multiple sclerosis, fibromyalgia, chronic fatigue, lupus, anorexia nervosa and bulimia (to name a few) to a double standard: If you are a woman who might suffer from one of these diseases, you get charged more on the front end in premium costs. But if and when you are diagnosed with one of these conditions, insurers routinely deny benefits when they are needed, or worse, cancel the insurance.

To quote Sen. Kerry, that is “just plain wrong.”

Late last month a New Jersey federal court approved a class action settlement requiring Horizon Blue Cross of New Jersey to expand benefits for its 1.5 million policyholders with eating disorders, reports the New Jersey Law Journal.

As a result, Horizon can no longer limit treatment it covers to 20 outpatient visits each year and only one month of hospitalization, and 556 patients will split a $1.2 million award. Horizon agreed that in the future it would treat eating disorders the same it would other biologically based mental illnesses.

The article points out that the settlement provides insureds substantially the same benefits they were set to receive in January when the U.S. Mental Health Parity Statute becomes effective.

Although in California, state law provides a much broader mental health parity statute, people with eating disorders often must run a procedural gauntlet to get carriers to pay for residential treatment. In a recent Kantor & Kantor case, the plaintiff paid for her own treatment while a federal judge required an appeal to the California Department of Managed Healthcare which punted the case to the California Department of Insurance, which then sent the case to an outside reviewer for independent analysis. While the review resulted in a ruling favorable to the plaintiff, the time spent obtaining it was detrimental to the patient’s recovery.

Class actions such as the New Jersey case against Horizon draw attention to the disparate treatment people with eating disorders – mainly women – receive from their health insurers. We hope California takes note and revises its procedural quagmire, which proves to be simply another stalling tactic and roadblock carriers can take advantage of to intimidate their customers.