Back in health insurance hell

SILVER CITY — I thought I was through with our horrible health system when I got old enough for Medicare. Once I got socialist health care, all my capitalist insurance problems went away.

But that was before pickleball. The pickleball phenomenon sweeping the nation — and Silver City — is the safest sport for old people. You can't possibly get hurt. But I did.

One minute I was preparing a killer shot; the next I was being lifted onto a stretcher by EMTs. Friends told me I was out for three minutes.

But this is not about sports injuries generally, or concussions specifically — although it seems a head knock can cause more problems for much longer than I had imagined.

Two months later, with most physical problems behind me, I started to get bills for copays and everything Medicare doesn't cover. I love Medicare when I have a good health year, but not so much in a bad year. The costs keep mounting. And you'll probably have more bad years as you get older.

So when open enrollment for Medicare plans started, I decided to look at alternatives to standard Medicare. But before we talk about them, let's look at health insurance in general.

The idea is that you bet your money against your health. You pay monthly premiums to get a health benefit. If you have good health, the insurance company keeps more than you paid in. If you have bad health, you get back more than you paid in.

So if you're angry at your health insurance company (and who isn't), the way of revenge is to get really sick or have a bad accident. And that's where the incentives get weird.

A private insurance company has incentives to charge you the highest rate the market will bear, and to give you the least health care they can get away with. Medicare, on the other hand, seems to want to pay for your health. The government will try to prevent fraud, but they don't need to

make a profit. The most obnoxious part of private insurance is that they want to put you and your physician into networks. I can't tell you how relieved I was to get out of network hell and onto Medicare. I'm not sure why insurance companies like networks, but it feels like a shakedown. This scam isn't for your benefit, and it's probably not for your doctor's benefit. The only reason to put up with it is — well, because you have to.

Still, if you have a bad health year with big expenses, you might consider alternatives. Let's imagine two people in that situation.

Molly is on a fixed income. She tries to budget, and doesn't want medical surprises. She wants to put enough medical insurance in her budget so that she has few or no copays. That's Medicare Supplement (or Medigap). She pays extra for a private policy that covers all or most of what Medicare doesn't. There are no networks.

Bart is a businessman. He is used to uncertainty and risk. He can afford extra payments if necessary. He wants the smallest total of premiums and copays for a "normal" year, and some protection for catastrophes. That's MedicareAdvantage. He chooses a private company that will use his Medicare premium for coverage. The idea is that maybe a private company can provide more complete insurance than the government. But this company will have a network, and the cost will be higher for care out of that network.

Let's stipulate that the situation is a lot more complicated than I describe, and that there are good and bad companies and policies and that, well, stuff happens. But a reasonable generalization is that in a good health year, Molly will pay more, but in a bad health year, Bart will pay more.

Bart will also have to deal with networks — which can be trouble in a rural area where providers are split between networks. That's why some local insurance brokers (did I forget to mention brokers?) refer to Medicare Advantage as Medicare Disadvantage.

But what if we could have Medicare that pays for everything for everybody, with no networks? That's the promise of the New Mexico Health Security Act (see nmhealthsecurity.org). This proposal has been debated for many years and is now being designed by a state agency.

Theoretically, it would be a big improvement for New Mexicans. It's hard to imagine anybody liking the current system, but apparently some legislators are more worried about possible future dysfunction than certain current dysfunction. I'll write about it someday.

In the meantime, the sign-up period for Medicare alternative plans ended earlier this month. I did my research. I made my choice. Tune in this time next year to hear how it went.

Bruce McKinney is a Silver City business owner, close observer of local government and occasional troublemaker. In his column, which appears every other Wednesday, he tries to address big questions from a local perspective. Send comments and ideas to [email protected]. The views expressed in this column are those of the author.