Recently, WWL-TV, the CBS afffilate in New Orleans, ran a story about Carol Raines, a New Orleans resident who has been unable to obtain a surgery that would allow her to eat. According to the story, Ms. Raines and her husband were robbed at gunpoint in 1980. One of the robbers murdered her husband, and the other attempted to murder Raines with a gunshot to the jaw. She survived, but has suffered from medical problems ever since.
The man who shot her, Dwight Powell, is now in state prison. (His accomplice is still free, because Powell refused to give police his name.)
Raines has, since the shooting, suffered from degenerative disease of the temporal mandibular joint, or TMJ, and over time the joint has deteriorated to the point where Raines can no longer open her mouth. Today she weighs 89 pounds and gets all her nourishment by drinking liquids through a straw. She needs joint replacements of both TMJs, but the artificial joints will cost $14,000, and her insurance will not pay for them.
The angle WWL chose for the story is that Powell, as an inmate of the prison system, would be eligible for the TMJ implants if he needed them, but Raines, the woman he tried to murder, cannot afford them. Although this angle adds to the sense of injustice of the story, I think WWL missed the more important point: Raines has health insurance. In fact, she has two plans, not one -- Medicare and United Healthcare -- and between the two neither will pick up the tab.
This is the real problem with health care in America. You may think you have health insurance, but you really only have the coverage your insurance company decides you can have. Few Americans, after all, really choose their health coverage. Most people take what their employers give them, or what Medicaid or Medicare offers. Very few people gets a choice -- in fact, the average auto insurance company allows buyers more coverage options than employers do. Carol Raines does not remember ever signing a document excluding TMJ replacements from coverage. But I promise you United and Medicare had no trouble finding the clause that allows them to do it.
The reason we don't have a decent health care system in this country is because about 70% of all Americans have either private insurance or Medicare, and sit fat and happy thinking they are covered. Certainly their insurance companies lead them to believe this is the case. The reality is that insurance serves most people well as long as the problems remain mundane, problems such as allergies, hypertension, or diabetes. When problems get complicated and expensive, the helping hands folks in the insurance business often do little more than help to hand their customers the bill.
A 2005 study by Harvard University showed that the average American who filed for bankruptcy that year had $12,000 in medical bills. Worse, 68% of these people had health insurance, and 50% of all filers cited health expenses as an important reason for their bankruptcy. The one thing insurance is supposed to do more than any other thing -- protect the client from the financial consequences of catastrophe -- is the one thing health insurance repeatedly fails to do.
I have patients like Carol Raines, patients who have suffered severe financial setbacks from medical bills despite having all the coverage they could possibly get. You could be the next victim. It could be only a single blood test, or trip to the ER, or as in Raines's case, a terrible misfortune not of your own making, away.
That is the story the WWL news story missed. Until we, as a nation, realize that even those among us with "good" health insurance are terribly exposed, there will not be meaningful health care reform.