The View From Your Sick Bed

by Patrick Appel

A reader writes:

Despite numerous attempts at losing weight, my father has been obese for most of his adult life. 10 years ago he was working at as a respiratory therapist at a prominent southern California hospital. He had very good health insurance. One of the many specialists he was seeing at the time recommended that he have gastric bypass surgery. Among my father’s obesity related illnesses were type II diabetes, hypertension, heart disease, asthma, sleep apnea, more than a few gastrointestinal disorders, two balky knees and several herneated discs in his lower back. All of my father’s specialists agreed that these conditions would be significantly improved if my father lost 100 pounds, and the cost of the gastric bypass surgery paled in comparison to the amount the healthcare industry would spend treating his obesity-related illnesses over the course of his remaining years. At first, my father was skeptical about having such a drastic procedure, but when he looked at it objectively, he decided that a drastic change was just what he needed to improve his failing health. Despite letters of support from several doctors of various specialties, my father’s insurer was extremely reluctant to approve the procedure.

But my father was persistent. He spent nearly a year filling out forms, filing appeals and visiting doctors and psychiatrists, jumping through every insurance company hoop. Then, just when there seemed to be a light at the end of the tunnel, my father’s employer laid him off along with half of his department. As soon as my father’s insurer learned that he was going to be extending his insurance via COBRA, they began completely stonewalling him about his surgery, because they knew that in a year he would be some other company’s problem.

At my father’s next job, his insurance was not nearly as good and the thought of starting the bureacratic process over again with an even slimmer chance of success was too much for my father to bear, so he dropped the idea of having the surgery. Then, three years ago, my father’s various ailments, primarily his knee and back problems, caused him to file for permanent disability. He moved into subsidized housing, living on a $1000 a month from the Social Security Administration. It was at that point that my father decided to get serious again about reducing his weight, and he began seriously reconsidering gastric bypass. He had health insurance through the California state MediCal program, but several years ago the state farmed out MediCal to private insurers, so what my dad actually had was very marginal insurance through an HMO.

Despite how futile it seemed, my father tried again with the HMO to get the gastric bypass procedure approved, but there were several barriers the insurance company had erected that made it almost impossible to get the procedure approved. One such requirement was that my father get an in-depth psychiatric examination that was not covered by the insurance. While it did not seem unreasonable for them to require my father to see a psychiatrist, it did seem ridiculous that the HMO refused to cover the cost of the visit which was over $700. You can imagine how difficult such an expense can be to someone living on $1000 a month.

Just when all seemed lost, something unbelievable happened. My father received a social security cost of living increase of $57 a month. Shortly thereafter, he received a letter from MediCal informing him that his insurance coverage had been terminated because he now made too much money to qualify for MediCal, but since he no longer qualified for MediCal, he was now entitled to receive Medicare coverage. Within 6 weeks of my father getting on Medicare, his gastric bypass procedure was approved and a date was scheduled. Medicare had identical requirements as the HMO regarding the procedure. The difference was that, unlike the HMO, Medicare paid for everything, including the psychiatric examination. My father had the procedure on July 3rd of last year. Since then, he has lost 120 pounds. He no longer suffers from sleep apnea. His hypertension, cholesterol and asthma medication doses have been reduced by more than half. He shows no signs of having type II diabetes, and his knee and back pain has improved so significantly that doctors are reconsidering the need for him to undergo knee reconstruction and back surgery, and my dad is planning to go back to work at the end of the year. He is currently working part time so that he can save up enough money to pay the back dues on his respiratory therapy license and return to work.

My father’s obesity related illnesses and time spent on disability have cost taxpayers an incredible amount of money. All of this could have been avoided if my father’s insurer 10 years ago would have been required to provide him the care he needed. But private insurers realize that the average patient only stays with them for 2-3 years, so they aren’t interested in reducing long-term healthcare costs because it’s the next company that sees the benefits. Hopefully, we can pass real healthcare reform that puts reducing healthcare costs above maximizing insurance company profits.