BBBS #8: For Your Health

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Making Sense of American Health Insurance

Biff Boff Bam Sock #8

Health insurance. The phrase alone is enough to make one crumple with mental fatigue. And what’s there not to be fatigued by? Health insurance brings to mind mysterious bills, fines if you aren’t covered, and ultimately the idea of impending and unknowable health issues as well as their monetary cost. But the main thing that I feel most would agree on is how frustrating is it to determine the best choices on their health, both pathologically and monetarily. I am just one of those confused people. But I am here to sort things out for myself and share the bounty of my knowledge. A little on my health insurance background: I am fortunate enough to have a mother who is a nurse, who always made sure I’ve had the healthcare I need. Thanks to the Affordable Care Act of 2010 (shortened to ACA, also known as Obamacare), I have been covered under my mother’s health insurance plan as a young adult. I’ve had the luxury of a slight delay in managing my own personal health care —1—

coverage. Once I crossed the age limit to remain on your parent’s health insurance (26 years of age) I had to make these choices (and premium payments) myself. I am an all-around healthy individual; no chronic disease or pending procedures but I do wear glasses, have some minor manageable health concerns, and I am a woman. I’ve also managed my husband’s health insurance (and lack thereof) when he was diagnosed with cancer, and the managing the treatment that subsequently followed over a period of a year. (sidenote: he is now in remisson, no worries.) I’m not a health insurance expert by any means, but I am nothing if not determined to learn about it to make the best choices for myself and my spouse. And subsequently share my methods and thinking with you, dear reader. Much love, Anna Jo Beck


Note I am doing my best to provide insight, but I am not a professional healthcare expert. This zine was written by a single person attempting to simplify a complicated subject. Just as every human body is unique, every American’s experience with health insurance is highly individualised. Also, laws change. I started writing this in late 2016 (pre-Trump), and by early 2017 (Trump inaugurated), change seemed imminent. Thus, I held off on publishing, but I can wait no longer. This zine was printed in autumn 2017. Some of the aspects of the American health care system may have shifted, but most of the general concepts presented will remain accurate. This zine is written specifically about the American health insurance system. I aspire to learn more about other countries’ approaches, but my goals for this zine is to be utilitarian for myself and my fellow confused Americans when signing up for a health insurance plan. One final note: this topic can be as tough and dry as a Trump steak (zing!) and I’ll be sure to pepper in some “mental pit stops” to give your mind a break from these complex and discouraging facts. Drink lots of water, take deep breaths. We’ll get through this together! —3—

What is it and do I need it?

What is health insurance? Health insurance is just like any other form of insurance: an arrangement by which a company or government agency provides a guarantee of compensation for specified damage in return for payment of a premium. You have car insurance to help cover the costs in case of a collision or repair. You have homeowners insurance to help cushion the blow in case of flooding or theft. Health insurance is meant to help mitigate the costs from a medical emergency or procedure. You don’t get insurance because you anticipate a tragedy; you have it to be covered in the care of a rare but financially costly event. Do I need health insurance? Yes, you should buy insurance - even if you’re young and healthy. Yes, you should buy insurance - even if you think you won’t use it. —4—

Also, it’s legally required in the United States by the The Patient Protection and Affordable Care Act, often shortened to the Affordable Care Act (ACA) or nicknamed Obamacare. Plus, you’ll be covered in case of an emergency, which can be extremely costly. Hearing me tell you that buying health insurance is a necessity probably is upsetting. I agree! I normally find comfort in making responsible choices, but I hate having to be responsible when it means I am federally obligated to pay a private corporation lots of money. But, relax, here’s an adorable toddler dressed as an elderly woman. The walker actually does help them be mobile! Ingenious!

The cost of not having insurance First cost: federal fee for being uninsured. As part of the ACA, insurance companies are no longer allowed to bar any individual from coverage based on pre-existing conditions (yay!). To compensate for this, it’s legally required for all citizens to have health insurance, or face a fee on your federal taxes. This annual fee is sometimes called the “penalty,” “fine,” or “individual mandate.” The penalty in 2017 is 2.5% of household income or $695 per adult and $350 per child, whichever is higher, taken out of your annual taxes. If you don’t have qualifying health coverage for more than 2 consecutive months of the year, you may have to pay a portion of the penalty for the months you’re uncovered. Second cost: any and all medical costs. Without health insurance, in addition to the federal penalty, you are personally responsible for all medical costs with no limit. According to the Health Care Cost and Utilization Project, in 2012, —5—

there were 36.5 million hospital stays in the United States, with an average length of stay of 4.5 days and an average cost of $10,400 per stay. That’s a ton of money! Healthcare is the number-one cause of personal bankruptcy and is responsible for more collections than credit cards. Having health insurance can lower your costs even when you have to pay out-of-pocket to meet your deductible. Insurance companies negotiate their rates with providers and you’ll pay that discounted rate. People without insurance pay, on average, twice as much for care. Gertrude Mokotoff, 98, and Alvin Mann, 94, tied the knot after meeting at the gym where they still work out twice a week. Alvin and Gertrude dated for eight years before she asked him to marry her. “I asked him to marry me,” she said with a chuckle. “I was tired of chasing after him.” “People always ask what it is that keeps us young,” Alvin said. “Of course, one part of it is medical science, but the bigger part is that we live worry-free lives; we do not let anything we cannot control bother us in the least.”


Choosing a health insurance plan In America, we have a system that treats health insurance like any other commodity: there’s a price and you have your freedom to choose from the available options. To make an informed choice, let’s familiarize ourselves with the basic vocabulary of the factors that will impact your cost and coverage. Types of Health Insurance Company Sponsored Plan: If you’re employed, and your employer offers health benefits, it’s usually the most cost effective way to be covered, as they chip in a portion of your monthly premium which lowers your cost. An employee’s share for only covering themselves on a company sponsored plan costs on average, $110 premium every month (though often more). If you’d like to cover your spouse as well, the average is $280/mo. If you have children, the average is $413/mo. (*note: these figures are from 2016, federal health insurance marketplace. Available plans (and their costs) depend on your age and location. Depending on your income level and family size, you may qualify for a discount on your monthly premium and/or your co-payments and deductible. If an individual earns less than 400% of the federal poverty line —7—

(<$48,240), you only pay a set percentage of the monthly payment. (ex: Someone earnings 200% of the federal poverty line (~ $24,000) is only expected to spend 4% of their income on premiums. That works out to $80 per month. The government pays the rest.) If an individual earns less than 250% of the federal poverty line (<$30,150) the recieve premium subsidies and cost-sharing reduction subsidies that reduce co-payments and deductibles. The idea behind this subsidy program is to make sure that low-income Americans can actually afford to see a doctor when they gain coverage. Even if you don’t qualify for any of these savings, you can get insurance through at the “sticker” cost. Federally subsidized health insureance programs: Medicare, Medicaid, and CHIP (the Children’s Health Insurance Program) provide low-cost, federally subsidized health care for those who qualify. Medicare, the most well-known of the bunch, is specifically for those over age 65, while Medicaid is meant for those with very low incomes (generally less than 130% of the poverty line, <$17,000 for an indivudual). CHIP is meant for coverage of children in low income families, who don’t qualify for Medicaid but can’t afford to buy insurance otherwise. The easiest way to determine eligibility is by applying for health plans through the federal or your state health insurance exchange. If you’re eligible, you can enroll in Medicaid and CHIP at any time of the year. COBRA: The Consolidated Omnibus Budget Reconciliation Act, better known as COBRA, lets you stay on your employer’s insurance plan for up to 18 months when you would otherwise lose coverage. It’s a very costly way to stay insured, as you’re paying the full cost without of your employer chipping in a portion of the premium. COBRA can still be advantageous if you need to maintain access to providers who may not be available under other plans, or if you know —8—

you have a big medical expense coming up and have already met your deductible for the year. In addition to these different avenues of obtaining health insurance, there are different types of health insurance plans:

Plan type

Do you have to stay innetwork?

Ideal for those who...

Traditional PPO


need more provider options and can afford a higher premium.


yes, except for emergencies

are fleixible with which healthcare professionals the see and also would like a lower premium.



can only afford the lowest premium but be aware the the deductible is very high; be prepared to pay mostly out-of-pocket.

This is Chendra the elephant. She was born in Malaysia and found orphaned and injured. She's blind in one eye and was a poor candidate for release so she came to Portland in 1999. The animal handlers at the Oregon Zoo took Elephant around to meet some other animals. The sea lions were her favorite.

Evaluating a Plan All insurance plans should provide you with a short, plain-language Summary of Benefits and Coverage (SBC). It’s a 6-8 page document, with the basic tenants of your plan. The document should start with a table that outlines the basics: deductible, what counts towards the deductible, out-of-pocket limits, and information on the network. It also has more information on your in-network and out-of-network costs for common medical events. Premium: The amount the policy-holder (you) or their sponsor (e.g. an employer) pays to the health plan to purchase health coverage. Usually this takes the form of a monthly payment to the insurance company. —9—

Deductible: The set annual amount you have to pay yourself for covered health care services before your insurance plan starts to cover your expenses. After you pay your deductible, you usually pay only a co-payment or coinsurance for covered services. Your insurance company pays the rest. When deciding between plans, the major principle is that there is a direct relationship between how much you pay upfront (your monthly payment to an insurance company [premium]) and how much you have to pay before the insurance company begins to cover a set portion of your bills (deductible). High premiums usually accompany lower deductibles; lower premiums, higher deductibles. I like to think of premium/deductible as the first line in your consumer choice. However, there are additional factors to consider that contribute to how much the coverage ultimately costs.

Cats and rats being friends? Not such a crazy concept at the Brooklyn Cat Cafe, a feline-centric establishment in New York run by Brooklyn Bridge Animal Welfare Coalition. The rats spend time with kittens younger than 8 weeks old who are separated from other cats until they’re old enough to be vaccinated. This is great especially for orphaned baby kitties, as the rats play with them and will lick them clean.

Co-pay: A fixed amount you pay for covered services, typically when you get the service. For instance, an annual doctor visit, or a emergency room visit are often given defined costs for your plan. Note: these most likely won’t count towards your deductible, but will count towards your maximum out-of-pocket. — 10 —

Co-insurance: Co-insurance, unlike a co-payment, is based on a percentage of a procedure, not a flat rate. Often, espeically on lower cost plans, you have to pay a portion of co-insurance on procedures even after you meet your deductible. Maximum Out-of-Pocket: In theory, this is the most you’ll have to pay during a policy period (usually a year) for health care services (aside from premiums). Once you’ve reached your out-of-pocket maximum, your plan begins to pay 100% of the allowed amount for covered services. That said, you will still have to pay your monthly premium if you reach your max out-of-pocket amount. Besides the outright costs, there is one last thing to consider: the network for a given plan. In-network refers to providers (doctors) or health care facilities that are part of a health plan’s set list of providers with which it has negotiated a discount. This is the perk to having health insurance! Out-of-network means that the doctor or facility providing your care does not have a contract with your health insurance company. This will be associated with higher costs for your visits, as they have not been negotiated. A plan’s network may or may not be a big issue for you. If you have a chronic illness and staying with your healthcare team is important to you, then picking a health insurance plan that has your doctor in-network makes the most economical sense. If you’re comfortable switching doctors, this may not be as large of a deciding factor for you. For a more exhaustive list of health coverage and medical terms, see the resources section. Assess your needs This is where it becomes very personal. There are lots of factors to consider in what health coverage you need: your age, if you have medical conditions, if you’re married, if you are planning on having kids, if you have kids already, your lifestyle, etc. — 11 —

Odds are, if you’re reading this zine, you are are on the younger end of the spectrum. When you’re young and healthy, there will be many years that you will end up spending more on premiums than your health plan pays out in claims. It stings but it’s the truth. Think of it this way, having insurance on a new car seems expensive, but you could get into an accident tomorrow, no matter how cautious you are. While it’s difficult to say generally how much one should expect to pay for health insurance annually, market data indicates that as you age, the price of healthcare increases. See chart:

Enrollment Periods You’re only allowed to make changes to your health insurance plan once a year. For federally run programs, open enrollment starts in the fall, typically November 1st. For employer sponsored coverage, it depends on your employer’s schedule, but most have it near the end of the year as well. There are several instances in which you can sign up for health insurance outside of the enrollment period. These exceptions are called Qualifying Life Events. Typically, it’s one of these four: — 12 —

• Loss of health coverage (loss of job, parental, or student coverage or losing eligibility for Medicare, Medicaid or CHIP) • Changes in household (marriage, divorce, having a baby, death in the family) • Change in residence (move to new zip code, seasonal worker) • Other (leaving jail, becoming a citizen, changes in income that affect the coverage you qualify for.)

Barber Franz Jacob has found ways to distract and relax six-year-old Wyatt Lafrenière, who is hypersensitive when it comes to having his hair touched. Wyatt has autism. To some with autism, the sound of scissors or buzzers cutting their hair bothers them. Wyatt doesn’t like sitting still and proceeded to lie down on the floor, so Jacob followed along. Wyatt's mother, Fauve Lafrenière, says that "usually hairdressers sort of panicked" when they saw her son walk through the door. "Franz takes care of everything, and I don't even get involved. It takes a load off my shoulders," Upon reading Fauve’s words of gratitude, Franz replied ”When I read that this morning, I cried," he said. "I don't see myself like that, but I'm just doing my best all the time here for my community."

Making the Final Choice With the exception of planning to have a baby or a specific nonurgent surgery, it is difficult, if not impossible, to predict your medical needs. Emergencies happen, procedures and prescriptions vary in price, or you might (hopefully) be completely healthy! Consider your known needs, call the insurer or your HR rep with questions. All in all, you do your best to estimate the coverage appropriate for you and your family. My optimistic advice would be to buy the best coverage you can afford and live a healthy lifestyle. My pessimistic advice is to actively seek an employer that has good benefits and take frequent breaks when comparing your options. It is exhausting. — 13 —

A Few Tips Mitigating Cost Many preventative care services will cost you nothing with the ACA in effect: Annual wellness visits to your doctor are at no cost (quick note: if you go in with a specific ailment, this will not be considered a “wellness visit” and be billed as a normal doctor visit). Many types of screenings (blood pressure, cholesterol, diabetes 2, depression, Hep B and C, HIV, Obesity, STIs, and more) and Immunizations (Hep A and B, HPV, flue, mbps, tetanus, and more). Women also are entitled to free generic contraceptives and free annual gynecologist visits. Be sure to look up which local hospitals and urgent care centers are in-network. If you have an emergency, you’ll be thankful to have this information on hand. When seeing a new doctor, call your insurance or look online to verify if they are in-network and call the doctor’s office to verify they take your insurance. Be aware that when a doctor refers you to another doctor, it is likely they won’t know who is in your network. Every time your insurance providers processes a claim, they will send you an EOB (Explanation of Benefits) in the mail. Review these to verify — 14 —

everything is in order. Billing mistakes are common, unfortunately. If you do end up with a sizable bill due to a hospital, try calling their financial department and ask for a discount and/or a payment plan. If you have the luxury of time before the procedure, it may be worth calling around to compare prices. There are vast differences in cost for some “shoppable” procedures, such as MRIs, cardio stress tests, and walk-in clinic visits. You can ask providers to submit a “predetermination” with your insurere to know how much your cost would be. Consider opening a health savings account (HSA) if you select a high-deductible plan that is eligible. You can sock away money in an HSA completely tax-free to help you pay for health care. Individuals can contribute up to $3,400 in 2017 as long as they are enrolled in a health care plan with a deductible of at least $1,250. Consider shopping your coverage annually. The price of plans will rise in most states, and the administration says that 86% of people who currently have coverage through the federal exchange can find a better deal by switching plans.

Newlyweds Clayton and Brittany Cook were posing for photos on a park bridge in in Kitchener, Ontario. “For several minutes these kids were following us, and I was just keeping an eye on them because they were standing close to the water. Then while Brittany was getting her solo shots taken I realized only two were standing on the rock ledge. I saw the boy in the water struggling to keep his head up. That’s when I jumped down.” Clayton jumped into the water and pulled the boy out.

Essential health document Once you do have your health care coverage in line, I really recommend creating a kind of fact sheet about your own plan. You can either keep this as a document online (best for easy access), or a — 15 —

physical folder you keep on hand. Some helpful things to include: • Your login information to • Links to your health insurer’s and your hospital’s online portals • The full name of you plan, and a hyperlink to (or a copy of) your SBC PDF • Your plan ID number, Your group number, BIN, TCN • Premium, deductible, and max out-of-pocket amounts • A list of out-of-pocket payments made and note if they count towards your deductible • General contact for your insurance carrier (and their hours) • The name, address, and phone number for your Primary Care Physician • Short summaries of doctor visits: date, time, who was seen, what was discussed • Prescription notes: name, dosage, how many refills, cost • Your pharmacy information: store name, address, phone number, and hours Kelly Turney surprised his wife-to-be on their wedding day by flying a stranger up to Alaska for the ceremony. This stranger was named Jacob Kilby, and he is alive because of a heart transplant received from this bride’s 19 year old son Triston, who had past away two years earlier. Triston’s other vital organs saved four additional lives, including a lung recipient whose family has since reached out to Becky after seeing her story. She hopes to eventually connect with the other recipients. “Those bonds that we’re creating are priceless. They’re healing,” she said.

Questions to arm yourself with *Note: these are basic, non emergency questions. I highly recommend you read An American Sickness for a more extensive line of questioning. Also, write down questions before, during, and after visitng your doctor. These notes are invaluable. — 16 —

Questions to ask when you’re choosing your doctor *Note: doctors are generally taught little to nothing about the cost of healthcare, but the best doctors will not be threatened by skeptical, questioning patients. • Is this practice owned by a hospital or licensed as a surgery center? If the answer is yes, you may be subject to facility fees. • Will you refer me only to other physicians in my insurance network, or explain why in advance if you can’t? • If I need blood work or radiology testing, can you send me to an in-network lab? • Will there be a charge for phone advice or filling out forms? Is there an annual practice fee? • If I’m hospitalized, will you be seeing me in the hospital? • What is your coverage on weekends? In your doctor’s office • How much will this test/surgery/exam cost? • How will this test/surgery/exam change my treatment? • Which blood test are you ordering, what X-ray, why? • Are there cheaper alternatives that are equally good, or nearly so? • Where will this test/surgery/exam be performed? At the hospital, at a surgery center, or in the office and how does this affect the price? • Who else will be involved in my treatment? Will I be getting a separate bill from another provider? Can you recommend someone in my insurance network? In the hospital • Avoid a private room: hospitals have built a huge oversupply of private rooms, though insurance frequently won’t cover their full cost. • Avoid out-of-network charges. In the pages of admitting documents you’ll have to sign, there is probably one concerning your willingness to accept financial responsibility for charges not covered by insurers. Before you sign, write in “as long as the providers are in my insurance network.” • Be clear on the terms of your hospital stay: are you being — 17 —

admitted or held under observation. Inpatient stay is less expensive. • Ask to know the identity of every unfamiliar person who appear at your bedside, what they are doing, and who sent them. • Refuse any equipment they try to send you home with, even if it’s covered. Bills • Don’t wait to negotiate prices or dispute charges. • When a hospital bill arrives in the mail, request a complete itemization. (This is your right). • Check the bill against the notes you made while in the hospital (billing departments often make mistakes). • Protest bills in writing to create a record.

Whitney Kittrell became a single mom over 3 years ago she made a promise to herself that she would do anything she could to give her children the same experiences as other kids, even if it meant going out of her comfort zone. When her kindergartener came home with a paper saying that they were having ‘dads and doughnuts’ her heart sank. She asked if he wanted to ask his grandpa to go. He just smiled and said ‘no. I want you to go. You’re my mom and dad’. She gathered up my best dad outfit, painted on some facial hair, and went to breakfast with my sweet son. She said she was embarrassed but she couldn’t help but smile when he introduced me to his little friends saying ‘this is my mom... she’s my dad too so I brought her!’

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My Opinions on Health Insurance

(Brace yourself; there are no fluffy breaks in this essay)

It’s no secret that healthcare is an incredibly frustrating, costly, confusing endeavor. Why is there a labyrinth between your average citizen and proper medical care? It’s because the system that once was a good faith intention has grown into a capitalist and regulatory mutant. It is a unique mix of consumer choice in an obscured market, complex federal obligation, and unimaginable risk that make it an unparalleled hardship. How much we spend The healthcare industry in America makes up nearly 1/6 of our economy. This is an often trotted out statistic that could use additional context to underscore what an enormous sum this is , especially in comparison to other countries. 18% of the USA GDP is spent on healthcare, more than twice the ratio of of other developed nations. What is that in dollars? Three point two trillion. Or $3,200,000,000. That’s broken down into these chunks: 20-30% doctors bills, 40-50% hospital bills, 15% drug and medical device costs, 20-30% bills for tests and ancillary services. (Insurance costs are not calculated into this bill at all). Combine this and you reach $3.2 trillion. That’s basically France’s entire economy. That’s $9,990 per US citizen. If our $3.2 trillion healthcare sector were its own country, it would be the world’s fifth-largest economy. — 19 —

And for spending twice as much on healthcare than other developed countries, we don’t see twice as good health outcomes. We actually perform much worse by comparison: The UN world wide assessment of quality of healthcare pegged us at 28th. The 2017 “Mirror, Mirror” report from the Commonwealth Fund revealed that the US ranked last overall among 11 industrialized countries on measures of health system quality, efficiency, access to care, equity and healthy lives. This study also ranked us last in access, equity, and healthy lives. We are an extreme outlier in the poor performance of our health system, compared to how much we spend on it. So why is it that we spend so much money on healthcare? In America, we operate in a capitalist society, and every marketplace has conditions that dictate incentives, prices and regulations. We treat healthcare just like we treat gasoline, furniture, or orange juice concentrate - as a commodity. But healthcare is different than those I listed in many ways: there’s not a lot of data we can use to inform our choices, be it by price (notoriously hard to suss out) or quality of care (how does anyone pick a doctor? Just ask your neighbor?). In many instances you don’t have a choice, be it by emergency or lack of options. And of course, there is no risk to your health/life if you delay on a Rate at which the choice of furniture. cost of hospitalization

150% grew from 1997-

2012. Cost of Elisabeth Rosenthal outlines 10 economic physician services rules of the dysfunctional healthcare market: grew 55%. 1) More treatment is always better. Default to the most expensive option. 2) A lifetime of treatment is preferable to a cure. 3) Amenities and marketing matter more than good care. 4) As technologies age, prices can rise rather than fall. 5) There is no free choice. Patients are stuck. And they’re stuck buying American. 6) More competitors vying for business doesn’t mean better prices; it can drive prices up, not down. 7) Economies of scale don’t translate to lower prices. 8) There is no such thing as a fixed price for a procedure or test. And the uninsured pay the highest prices of all. 9) There are no standards for billing. There’s money to be made in bill— 20 —

ing for anything and everything. 10) And lastly, the mother of all rules! Prices will rise to whatever the market will bear. (You can read about these in detail in her article here: A brief history lesson At the start of the 20th century, medicine was obviously not as effective as it is now. Health Insurance, sponsored by Blue Cross Blue Sheild, began as a non-for-profit safety net from bankruptcy if you were hospitalized long term and (against sizable odds) happen to survive, as well as a way to keep hospitals (that were ran by charitable religious groups) afloat. When salaries were frozen during World War II, health insurance was offered by employers to attract scarce laborers. The 15 years between 1940 and 1955 saw an increase of insured from 10 to 60%, and all members were charged the same rates, by what as still a nonfor-profit organization. This is when for-profit companies (Aetna, Cigna) came into being and eventually (in 1994) forced BCBS to become a for-profit to compete. To increase profit, tons of money was (and is) spent on lobbying, marketing, administration, and paying out investors. Less money was spent on actual medical care. These costs were (and continue to be) passed down the economic chain: between 1967-83 Medicare payments increased from $3 billion to $37 billion; hospitals set the rates, and insurers/patients were expected to pay. When regulators came in to control this insane spending, consultants came to hospitals to help them increase revenue by manipulating the way they bill (“strategic pricing” and “upcoding” and “facility fees”). Many non-profits abuse their non-profit status (avoiding property tax, all levels of payroll taxes, tax deductible donations, and tax free bonds for building projects). Doctors fractured in alliance from their hospitals, gaining the ability to bill separately (buying their own medications and marking them up, billing for “extenders”) or other individuals to act and bill in their place. Medicines evolved from public goods to marketable commodities, with patents in place to inflate prices with little care for relative effectiveness or improvement. — 21 —

This leads to more middlemen in the prescription drug economy (PBMs and GPOs) to negotiate prices (and of course take their cut). The motives of our hospitals, doctors, specialists, prescription drug companies, ambulatory revives, device makers, medical associations, and of course insurers, all shifted from serving the patient to generating profits. The American healthcare system treats patients’ wellbeing as a widget of commerce: revenue generation, supply chain optimization, minimization of tax liabilities, innovative business modeling. Things sold. Services rendered. Bills to be paid. Customer Satisfaction not guaranteed I think the biggest element of why healthcare is confusing is the unimaginable risk you are expected to pay for now and to prepare and save money for in the future, yet you still have the potential to go in debt. What you will spend on healthcare is unknowable, and the idea of draining your savings on top of getting injured or ill, even with health insurance, is terrifying. Getting sick is a factor in 62% of personal bankruptcies -- an increase from just 8% in 1981. Among those who filed for bankruptcy, 75% reported having some type of medical insurance. The Washington Post says people in bankruptcy with insurance were nearly $18,000 in debt. Those without insurance had an average of almost $27,000 in medical debt. In fact, 1 in 4 uninsured people will lose all their savings to medical bills. Ways other countries control their medical costs reflect their values, political realities, and medical traditions. Some use fee schedules and national price negotiations (Germany, Japan, Belgium) and some use market-based tools of transparency (Singapore). Others use single payer (Canada, Australia, Taiwan). In a single-payer system, everyone has the same policy and provider, usually their national government. — 22 —


Kaiser calculates that deductibles have risen more than six times faster than workers’ earnings since 2010.

This results in an overall lower cost of coverage per person because this a centralized health care system results in massive buying power to negotiate with pharmaceutical companies and hospitals for lower rates. Another benefit to single payer is internal efficiency. You only need one way to make claims, not different ones for every company, and there no special negotiated rates or networks to navigate. The advertising budget would plummet, because there’s no competition. And, on a larger scale, it’s a more ethical approach. Do people have a right to life; a right to equal care regardless of income? Or, is it just another commodity you buy? Unfortunately, the system is set against us and healthcare providers actively profit from our complacency and ignorance. Being a savvy consumer is exhausting. The onus is on you to understand the system while advocating for your own interest, both medically and finanThe average hospital cost per cially, with rules and networks that day the United States, which change without warning. You are is more than 3x the cost in responsible for picking from limAustralia and 10x the cost ited (and often expensive) healthin Spain. care plans, through the ACA or an employer, or knowing your eligibility for Medicare or Medicaid. You are responsible for setting up appointments with doctors. You are responsible for cross-checking with the doctor’s office and your insurance that they are in-network. You are responsible for safeguarding yourself from out-of-network fees, and potentially unnecessary testing, while having no access to data to inform your choices. You are responsible for every dollar they bill you.


Ultimately, the cost and the hassle actively disincentives people from obtaining the care they need. According to the Commonwealth Fund report, more than one-third (37%) of U.S. adults reported forgoing a recommended test, treatment, or follow-up care because of cost. This is serious; as Kaiser Family Foundation researchers note, about half of all Americans — or 117 million — have some kind of chronic illness that requires medical attention. KFF also found about 14% of people — 23 —

with a chronic illness have put off treatment because of cost. So, now what? In this current political climate, it’s hard to have a discussion of political theory over the roar of “repeal Obamacare.” But the things people complain about the ACA are things that won’t be solved by repealing it (and could potentially get worse) such as: high premiums and deductibles that get worse every year or not being able to keep an insurance plan or doctors year to year. It’s because the ACA is reliant on private insurers that these are issues, and frankly they come out relatively unscathed if the ACA is repealed or not. But some of the arguments against the ACA are the result of fundamental differences in what people believe: they feel that the government shouldn’t force people to buy health insurance and that the Medicaid expansion is “a handout.” I find it hard to comporomise on these ideas. But if we gave all Americans a public healthcare option, then the mandate to have insurance of Americans said could be less burdensome, as the cost would they did not have inevitably be lower. How could you consider enough money a public option for all to be a handout if to cover a $400 everyone had access to it? emergency expense


Also, if we repealed Obamacare, that would include taking away the measures in the ACA that are extremely popular. People with minor pre-existing conditions such as high blood pressure, diabetes, and asthma will have significantly higher premiums. Teenagers would be responsible for the choice of having and selecting their own health insurance. Preventative services would no longer be free. Ideally, we should fix the larger issues in the healthcare sphere, not just this piece of legislation. We should insist on price transparency and standards for billing from our hospitals and insurers. We should demand that hospitals in our network guarantee all doctors and services rendered there are also in your network. We should require — 24 —

nonprofits to either follow their mission of “providing affordable community-minded care” or pay their taxes. We should have antitrust laws to prevent consolidations that reduce competition (which inflates prices). These goals are lofty, but I’d bet most people would agree there should be more consumer protection in this field. I think the way to real change is having conversations to find middle ground. Americans all demand to have choices when it comes to their health. From my perspective,our current choices are clouded at best, completely and strategically unpredictable at wost. Surely we can work together to demand that our choices be our own, and reign in cost at the same time.

Final Thoughts Parsing through mine and my husband’s health insurance options legitimately brings me despair every year. During this process, I feel nauseous; often on the verge of tears at the futility of it all. I can’t tell you how many times I asked my computer screen out loud “how do people do this?” and “why is this so difficult?” It’s an annual tradition of considering how we will we afford this intangible product we may not even use, while contemplating the fact that despite all my planning and evaluating, even my best financial choice would be a minor comfort if my spouse got cancer again. It makes actually putting this zine out difficult on two levels: I don’t feel I fully understand everything about health insurance and all it’s ever changing complexities, and because it’s frankly the most anxiety/ dread inducing topic I’ve ever come across. But here I am, trying to teach myself how to work within this system, and help others with the same plight. I hope this zine encourages you during your healthcare shopping and fuels your rage at how unfair a market based healthcare system is to us as patients and citizens of the wealthiest country in the world. We deserve better. We should demand it. — 25 —

Resources An American Sickness by Elisabeth Rosenthal It’s an amazingly well researched and well written book that echos much of what I wrote here. It took me many months to finish it, taking pauses every couple of chapters to beat down my rage at how twisted our system is. Pretty straight forward. This is where you would see what your options are in the federal insurance marketplace, apply for federal assistant programs, and talk to a Navigator, a person whose job it is to help you make these choices. You can also find someone to help you in person at, and there’s a 24hr hot line at 1-800-318-2596 Glossary of Health Coverage and Medical Terms

4 page PDF of explanations of commonly used terms. Also has a good explanation of how deductible, coinsurance, and out-ofpocket limit can interact over a year. A Healthcare Reporter’s Advice on How She Picks Health Insurance

Sarah Kliff gives a great rundown on how she, as a healthcare reporter, does her own health insurance shopping. (spoiler: it’s just like everyone else.) — 26 —

Reddit’s Personal Finance Forum’s post on Health Insurance 101

This is a great one. Very thorough, slightly more direct and expansive than Sarah Kliff ’s piece Mirror, Mirror 2017: International Healthcare Comparison

A very visually friendly annual comparison of 11 developed countries produced by the commonwealth fund. They’ve done this comparison every year since 2010. Separating Obamacare Facts From Fiction

Article answers dozens of common questions/myths about the ACA; problems with the website, death panels, etc. Reddit’s Explain it like I’m 5 on What the ACA Did Exactly

A pretty exhaustive list and explanation of the dozens of regulations the ACA put into law. Definitely worth a deep dive! Further Reading & Resouces on My Google Doc:

Simple doc organized by topic with a sentence or two explainer for each entry. Topics include: choosing an insurance plan, world wide data, USA data, ACA, researching costs, healthcare news, podcasts, writers. Also includes links to all the resources here (if you didn’t want to type all those long URLs).

Thank yous: My deepest gratitude to those who helped me edit this tome: Yubizaly Centeno, Lisa Beck, Greer Mosher, Julia Romano, and Katie Lafferty. And thank you to Miguel Centeno, for encouraging me to make these intense and (hopefully) enlightening booklets. — 27 —

And of course, thank you reader. Congrats on getting through this. Health insurance is neither fair nor just, but being knowledgeable will help us deal with it in the present and reform it in the future. You’ve earned a lollipop treat for being such a good patient!

Check out my other zines: Biff Boff Bam Sock #5: Personal Finance Guide Biff Boff Bam Sock #6: Spanish Grammar Guide Biff Boff Bam Sock #7: Stuff We Have From Cancer — 28 —

For Your Health by Anna Jo Beck is a how-to zine on health insurance. It covers how the American health care system works, how to pick a health insurance plan, her opinions on the entire healthcare economy in the United States, and several moments of cute, heartwarming distraction to keep you from wanting to totally give up hope.

P4 What is it and do I need it? What is health insurance? Do I need health insurance? The cost of not having insurance P7 Choosing a health insurance plan Types of health insurance Evaluating a plan Assess your needs Enrollment Periods Making the final choice P14 A Few Tips Mitigating cost Essential health document Questions to arm yourself with P19 My opinions on health insurance How much we spend A brief history lesson Customer satisfaction not guaranteed So, now what? Final thoughts P26 Resources

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