By Cindy, Boomer Volunteer

In 2009, I walked away from a 20+ year career in health insurance.  It was a hard and yet an easy choice.  In my career I experienced a lot of changes to the health insurance industry.  And the industry was no longer a pretty picture to me.  Personally, I had dealt with the long-term health care of both parents, medical issues of children, and the terminal illness of my husband.  Professionally, I kept working away, including earning a Managed Healthcare Profession designation through America’s Health Plans (AHIP).  But the longer I worked, the more I questioned our insurance system.

When I first became involved with health insurance, base plans were still common place, such as paying 100% of hospital expenses for a set number of days.  Comprehensive Major Medical plans were the popular trend.  Computerized claim payment was a new trend, requiring much manual interpretation from bills.  Over the years, I worked with initial cost containment efforts, such as pre-authorized medical procedures.  We had a bit of a family attitude in our company at that time, and we felt like we performed a helpful task.  During the early 1990s, HMOs, PPOs and utilization review exploded, medical costs escalated and demands grew within health insurers to cut costs.  Benefit plans and claim processing became increasingly complex.  Our mantra over time became that “we do not know how we could understand insurance if we did not work in the insurance industry.”

For health insurers, the 2000’s brought more pressure for internal cost reduction, plan   cost sharing and further health provider management, such as creatively limiting physician and hospital payments.  We dealt with complex physician/hospital payment contracts, more complex claim payments and more payment errors.  Like our clients, my colleagues and I were offered a high deductible health plan.  We were keenly aware that plenty of health plans were better than our company’s plan.  I started hearing how fellow employees avoided care because of costs.  There were rumors about mergers of insurance companies to have better economies of scale due to the potential of some form of national health insurance (insurers actively fought healthcare reform during the Clinton administration).  Industry layoffs started occurring and work stress increased from corporate cost cutting.

At the same time as stress increased at work, my husband was diagnosed with cancer.  Like me, he also worked in insurance.  He worked in medical underwriting – the people who permit or deny coverage when applying for individual coverage.  Ironically, after his diagnosis he immediately knew that he would not qualify for individual health coverage again.  He had a pre-existing condition. He also shared the genetic condition that caused his cancer with our two children.  He knew that although our kids rarely need medical care for their condition now, they too will likely be excluded from individual health insurance coverage. 

Until he passed away in 2007, my husband was haunted with the prospect of health insurance exclusions for our family and the overall changing health care environment.  He was also very saddened from encountering another issue in our health care system.  One of his employees had to declare bankruptcy because of a child’s illness.

Even though my husband and I worked in the health insurance industry, we were in the same boat as many Americans.  We were exposed to issues that are all too common for all – overtly complex insurance plans, pre-existing conditions, delaying care due to cost or under-insurance, and bankruptcy due to costs of medical care.

What words of wisdom can I provide from my health insurance experience?  First, ObamaCare provides solutions and/or relief for many issues.  My children will not be denied coverage by health insurers because of the pre-existing genetic condition they share with their father.  ObamaCare provides the most personal protection, best safety net, fairest coverage and most simplification that we have going at the moment!  I pray that the Supreme Court ruling does not upset the Patient Protection and Affordable Care Act’s provisions.  Second, based on the scope of the health insurance industry’s involvement in reform, my perspective is that health insurance will remain fairly complex and vary in practice by individual insurers, and therefore must be regulated and must have oversight to protect consumers.  High deductible plans remain as an option in both health exchanges and non-exchange plans, which means that there are still potential issues of care postponement and personal bankruptcy issues. 

The Bottom Line: ObamaCare will benefit us!  I optimistically see it as a first step to fair and affordable care.  However, I also believe we need to be educated and vigilant of the influence of health insurers.  We must be aware of what is going on with health reform to assure an adequate, reasonable and beneficial system.  Large health insurers have a great amount of influence, and, sadly, profits rule.  In the end, however, we need to make health reform prevail for all of us.  

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