CRAZY AMERICA: Health Insurance Covers Testing When You Are Well But Not When You Are Sick

Insurance is the wrong word for what we have here. Our private health insurance system’s prioritization of sometimes frivolous screenings but non-coverage for common illnesses and emergencies is a travesty and an insult to typical American middle class families.

State Medicaid insurance for the underemployed has minimal copays of just a few dollars for doctor visits and medications. From my vantage point as a physician, it is the best insurance a patient can have. They cover almost everything and it is clear to me how to apply for exceptions or follow their step care requirements. I cannot say that about most other insurers.

Most employed people have the kind of commercial health “insurance” that covers an annual physical and certain screening tests at no cost, but requires people to pay the first several thousand dollars of actual sick care expenses out of pocket. This is, in my opinion, insane. It causes delays and omissions in diagnosis and treatment.

A shining example of this bizarre arrangement is the screening colonoscopy. It is free as long as it is normal. If a patient has a polyp removed, which if unchecked could turn cancerous, future health care costs for treating colon cancer are eliminated. But the patient gets billed for the early cure.

The pandemic we live under has demonstrated the thin financial margins many Americans live with. A couple of months of missed paychecks and suburban families are lining up at food pantries.

The high deductibles and the high and often undisclosed cost of health care tests and procedures can be more than enough to destabilize an average American family’s economy. Under such circumstances people hesitate seeking care for new symptoms, even if they seem serious.

Historically, the word insurance is derived from the Old French ensurer, meaning “make safe”. The word assure is an even older word, long used specifically for providing a guarantee against loss in exchange for money. American health insurance has drifted into higher and higher deductibles and people now feel less and less safe for having health insurance.

I have many patients who, because of the cost, hesitate getting the lab work to monitor their chronic conditions and to ensure that their medications aren’t causing adverse effects. At the same time, I have patients who are perfectly healthy and take advantage of the “free” physical and random blood tests year after year. But if you feel fine and your weight and lifestyle never change, chances are your blood count, chemistries or lipid profile won’t change much from year to year either.

In fact, annual screening blood tests and even routine “complete physicals” have little or no proven value, depending on exactly who you listen to, including the US Public Health Service Taskforce on Prevention. However, an annual review and conversation around specific health screenings, immunizations and disease prevention, such as the no-touch Medicare “Wellness Visit” has been shown to improve compliance with preventive care guidelines (often called quality).

The whole concept of health insurance is confusing because it is so different from other types of insurance.

My car insurance only pays for accidents. They don’t pay for my state inspection, scheduled maintenance or normal wear and tear, and certainly not for mechanical failures. A brand new or certified used car, on the other hand, may be covered by a “bumper-to-bumper” warranty for a few years, but never for its entire useful life.

There is complete disagreement about how health care should be paid for. Socialized medicine and insurance medicine are two very different models. Americans seem to intuitively, emotionally, want to think of commercial health insurance as something a lot closer to free health care or a car warranty than it actually is. Commercial health insurance is a for profit enterprise that happens to be in the health care field. Their ultimate reason for existing is to make money. They do that by paying out as little as possible and keeping as much as possible of our premiums without looking unacceptably greedy.

I left Sweden with the insight that its socialized healthcare system had many inefficiencies and much bureaucracy. I live in America with the insight that a government bureaucracy, like our Medicaid, is easier to understand and navigate than a hodgepodge of federal, state and commercial payers. And it saddens me to see the insecurity of my fellow Americans who risk getting bankrupted by health care expenses and inadequate sick time benefits or disability income protections – many of them, just like health care, provided by for profit insurance companies.

1 Response to “CRAZY AMERICA: Health Insurance Covers Testing When You Are Well But Not When You Are Sick”


  1. 1 DrJKH October 25, 2020 at 12:01 pm

    Anything you don’t like about health insurance can be traced directly back to a government intrusion into the industry.


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