Copy of article we did for newspaper in February 2000. However, things have changed a lot since then! This article is for reference only. - J S


When first conceived, "health insurance" was a concept by which large insurance carriers would provide financial coverage for the catastrophic medical expenses a customer incurred, and the customer would be responsible for his doctor appointments, prescriptions, check-ups and such. Along came the military and large corporations, with the idea that they would provide a more attractive plan to employees and cover more of the small costs, such as excess expense for doctors, drugs, diagnostics, etc. Then Medicare developed the idea of cost containment for seniors, with support from Social Security, and from that concept came HMOs, the government's attempt to contain costs for families and individuals who were not on government or corporate plans. Then came PPOs, by which a "Preferred Provider Organization" offered reduced rates for their services when provided through an insurance carrier who contracted with that organization to negotiate those discounted fees. "PPO" is not synonymous with "doctor co-pay," though we have come to think of it that way since those plans have become so popular in the last ten years. PPO networks exist both with and without co-pay programs.

Those of us who worked for "Corporate America" got used to $15 doctor visit co-pays and $10 prescriptions, with nary a clue as to how much these plans were actually costing our employers. When we left those jobs and were offered COBRA, we yelled at the high cost - still not understanding that that so-called "high cost" was simply the premium our employer had been paying for us all along. When we went out to find our own insurance, we were indignant to find that it could be pretty expensive when we picked up the tab. Some consumers actually thought it unfair that insurance could cost so much!

I constantly hear, "Where's it going to end?" or "We need to have socialized medicine!" (be careful what you wish for) or "How can the insurance companies keep gouging us with these high rate hikes?!"

Listen up, readers: we did it to ourselves. You, me, Corporate America, government... we did it, no one else. Consider: when we bought our car and took out auto insurance, did we ask the insurance company to pay for our oil changes and tune-ups? No; we asked that they cover the crashes and crunches, and we would cover all maintenance. When we bought a house, did we ask that the homeowner's policy cover new carpet, torn screens, garbage disposals or burned-out light bulbs? No; we asked that it cover the leaky roof or cracked foundation, the fire or  the flood damage.

So why do we believe that health insurance is supposed to cover our body's equivalent of oil changes and tune-ups, garbage disposals or light bulbs? We have got to start taking responsibility for paying for our own maintenance  and stop asking insurance carriers - whose original design it was not - to do this for us. Until we do, costs will keep escalating. Since the insurance carrier's only source of income to pay for claims comes from premiums, it only stands to reason that the more we want them to pay, the more we will pay for the privilege. If we aren't paying for these things, who is?

HMO's can be more expensive than insurance plans, because they absorb more of the cost so the con- sumer can have those low co-pays for that occasional doctor appointment or prescription. And some insurance plans cost more than others because they, too, offer competitive co-pays for... the occasional doctor visit or prescription. You get the idea:  the lower the co-pay, the higher the premium. And if you have costly prescriptions, any carrier will build their cost into the premium, as well.

Prevailing statistics show that in any given year, over 90% of the claims submitted for any one person to a health carrier, total less than $1,000. Consider: no one ever went bankrupt paying a deductible.

Go a step farther.... if you go to the doctor once a year for a check-up and get a cold maybe that often, what would be the out-of-pocket costs for those two visits - $250, maybe $350? (We aren't talking about getting an EKG or full heart work-up, but a typical annual exam.) If you take a doctor co-pay plan and pay only $25 for each visit, that's $50 out of pocket - as opposed to $250-350. But what if the difference between a $1,000 deductible plan with co-pays and a $1,000 deductible plan without doctor visit co-pays, was $75 per month? Could you afford to pay that $350 out of pocket if you knew you were going to save $900 on your premiums? Of course! And even if you did have several doctor visits or major services, the out-of-pocket would still be limited to the deductible and coinsurance limits (usually 20% of the next $10,000).  Remember, while co-pays don't count toward a deductible on a  co-pay plan, the cost for doctor visits and prescriptions does count toward the deductible on the old-fashioned indemnity plans.

Readers, this is a good part of why costs keep going up. We want the health plans to cover more of our out-of-pocket expenses for our care than we are willing to pay, but we don't want to pay the higher premiums that have to be charged in order to cover those costs! That's what can't continue; we have to take responsibility for paying for our basic care and maintenance, and stop forcing the HMOs and insurance carriers to provide them for us. We have to realize that we are going to pay one way or the other; until we make the decision to keep the costs down on the premium side by taking a plan which lets us pay more of the "smaller stuff," rather than pay the higher premiums of a plan with co-pays - whether we use the plan or not - premiums will keep going up. They have to: carriers can't keep paying for our every medical expense if they aren't collecting higher premiums with which to do so.

I realize this doesn't address the issue of those who can't afford medical care or who have already developed preexisting conditions... or the individual who has a plan whose rates have gone sky-high but who can't leave that policy because he has developed an uninsurable condition... (thankfully, he has insurance). Those of us who are not currently in that situation need to thank our lucky stars and God that we are in good health and can still make good financial decisions, take more control of and responsibility for how we handle medical expenses and stop asking others to pay for it.

Socialized medicine? If you don't like HMOs, you won't like socialized medicine. If you don't like the idea of the government telling your doctor or hospital how to run their business or what they can or cannot do, you won't like socialized medicine. If you don't want higher taxes, you won't like socialized medicine (that's where the money comes from, you know). High risk pools, guaranteed health plans for the uninsurable? Yes, those certainly have merit - and require higher taxes. But in the meantime, for most of us, it's about responsibility: insurance is a business, and the more we ask of it the more it will cost. The more responsibility we take for those costs, the less it will cost us in the long run.

Insurance as it was designed in the beginning is still the right idea: we pay for the little stuff, it pays for the big stuff. Not a bad idea, when you think about it.....

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