Santa in July: Tips for Health Insurance Companies That Don’t Know How to Spend Our Money

Earlier this year I took out indemnity insurance with Empire Health Choice, fulfilling a promise to myself to buy some sort of coverage after seven years of playing the numbers. Indemnity insurance is, in short, ’emergency insurance’, popular among artists who can afford little else. It covers in-patient hospital care – provided, of course, that the hospital is within the company’s circle of friends. That means all the lab work must done in the hospital’s lab and not outsourced to a facility that might do a better job of it; any specialists who deal with my case must be employed directly by the hospital; and, failing all other red tape, the insurance company – and not my physician – must deem whatever treatment I receive absolutely necessary.  So, for example, if my physician says a hospital stay was necessary to set my broken leg, but Empire Health Choice insists my broken leg could’ve just as easily been set in the hospital parking lot, then heaven forbid Empire Health Choice cough up a single cent for a luxurious hospital stay, even if that hospital is among their circle of friends. (The paperwork the company sent when I first joined recommended that customers remember to ask before receiving any treatment whether their doctors are directly employed by the hospital. Here’s hoping that if the time comes when I need to use my plan, I’ll be lucid enough to ask for such important information and not too preoccupied with whether I’m going to live or die.)

When I signed up I thought the plan was better than nothing. But after six months of sending in checks for $181 and each time imagining how I’d have to instruct the ambulance driver to take me to an in-network hospital rather than the closest one, I was starting to feel jaded about my great desire to be among the privilege insured. Even when Obamacare received the stamp of approval from the Supreme Court this month, I felt about as thrilled as I would have if Tiffany’s announced it was slashing the prices on all their platinum pendants by 50%. Great that President Obama has been spared the humiliation of having what little was left of his healthcare reforms squashed by the highest judges in the land, all of whom I’m sure are fully covered in case of an emergency and would never have to ask whether the surgeon about to cut them open is on the hospital’s payroll. But what’s there to celebrate in having comprehensive coverage a little less unaffordable than it used to be, but still very much out of reach?

All of this is leading me to the unexpected surprise I got in the mail last week. A letter showed up from Empire Health Choice, long before my next payment was due. I opened the letter, and a check tumbled out, a check made out to me. To me? From an insurance company? With no visit to the hospital, no arguing back and forth about whether or not my procedure was covered by my plan? This had to be a mistake. I quickly perused the enclosed memo and learned that the Affordable Healthcare Act requires insurance companies to issue a rebate to customers if the company does not spend at least 80% of customer premiums on health care services (i.e. doctors and hospital bills and ‘activities to improve healthcare quality’). Last year Empire Health Choice fell short by just over 10%, spending only 69.4% of $3,767,992.20 received from premiums. Yay for Obamacare! Yay for an unexpected check in the mail! Yay for an extra $28.44 to put in the bank! But as the thrill of the moment began to fade, I did a few calculations. Empire Health Choice raked in approximately $400,000 last year, not a cent of which went toward the cause of providing health care to its clients.  What ‘activities to improve healthcare quality’ could that money have funded?

• Three years of weekly visits to a mental health practitioner (at $50 a visit) for the 48 people who committed suicide in New York last year.
• A year’s membership to a local YMCA for 400 families, including parents and their dependents aged under 18. (This is especially pertinent in Brooklyn and the Bronx, both ranked within the bottom five among New York’s unhealthiest counties in 2011.)
• An annual teeth cleaning and oral exam, including four X-rays, for 2,000 adults.

It’s all too easy to find ‘activities to improve healthcare quality’ in New York. So why on earth should I be receiving a rebate in any amount? My premium could go toward the health of so many people – myself included – if the plan I was paying for prioritized care to any realistic degree. And I would happily fork over my $181 a month if it did. But for now, I’m paying for coverage in the unlikely event that I will find my way to an in-network hospital in an emergency, and once there, be in the frame of mind to investigate which anesthesiologist, physical therapist, surgeon or oncologist is on payroll at that hospital rather than which anesthesiologist, physical therapist, surgeon or oncologist is best qualified and readily available to treat my ailment.

I suppose the idea behind my suddenly becoming $28.44 richer this week was to urge Empire Health Choice to adjust its allotments to include more ‘activities to improve healthcare quality’ and fewer executive bonuses. And of course, it makes Obama look like Santa Claus in July, and who wouldn’t want to elect Santa for President? In the meantime I’ll spend my money on extra carrots and greens, and hope that by the time I do need to make a claim, the healthcare system will have evolved into something that puts people before profits. But I have the nagging feeling that revolution, and not evolution, is the only way this monstrous profit-making machine will ever change.