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From Other Pages



By Mark L. Horn, MD, MPH, Chief Medical Officer, Target Health Inc.



Regular readers of On-Target will recognize that, customarily, medical publications serve as sources for this Policy Section. This week we shall deviate and instead look for inspiration to the May issue of Commentary Magazine a (self- described) “independent journal of thought and opinion” published by the American Jewish Committee.



Novelist Jesse Kellerman provides this inspiration with a tale of his efforts to purchase health insurance in the individual market, a tale which will resonate with many and terrify most. As a self-employed author, Kellerman relied on his more traditionally employed wife for health coverage; when she left her job the couple needed to obtain insurance on the ‘individual’ market, and Mr. Kellerman began his journey through insurance purgatory. Skipping many of the gory details (and I highly recommend reading Kellerman’s piece in Commentary; consistent with its provenance, it is well written and highly entertaining), in essence Mr. Kellerman was denied coverage due to a pre-existing condition, a condition which made him a (potential) surgical candidate. The fact that conservative therapy had eliminated his symptoms and he did not need or want surgery proved irrelevant. To secure coverage, he was ultimately forced to endure an unwanted operation with its attendant complications.


The ‘physician’ in me found this narrative so outrageous that for a brief time I thought it must be a fictional account (the author, after all, writes novels), a bit of ‘medical gallows humor’. Sadly, I’ve concluded this saga is real, fitting comfortably into the category of ‘you can’t make this stuff up’.


Closing the health care policy circle, the sad irony is that the situation described here is one which I suspect virtually all Americans would agree needs to be fixed. Yet, guaranteed issue insurance at reasonable rates is precisely that component of the Affordable Care Act most at risk. Even the Administration agrees that this specific element of the Act must go if the Supreme Court rules the individual insurance mandate unconstitutional. Therefore, there is risk that, after all the effort, rhetoric, and obloquy, we may be left with hundreds of pages of costly rules and regulations broadly impacting health care delivery without a fix for a (perhaps THE) key problem plaguing Americans around which consensus may have been achievable, the inability to obtain reasonably priced insurance for those with pre-existing conditions.


How did this happen?


Was it Congressional overreach, political intransigence, a hopelessly divided polity, excessive influence of ‘experts’ with agendas inconsistent with the broad public interest? It’s impossible to know; all (or something else entirely) may have played a role, but the reality is unsettling. We had a chance to fix an insurance system which, based upon Mr. Kellerman’s experience (likely not at all atypical), is highly dysfunctional. If that opportunity is lost, it is by no means certain that there exists the ability, or political will, to reconnoiter and try again. Sadly, we are all losers in this.


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