Imagine you are one of the millions in this country who can’t get health insurance because you have a pre-existing condition. Now roll the clock forward to January 1, 2014 and walk with me down the virtual hallways of a brand-new marketplace, a marketplace where you can buy some peace of mind and help for your family, no questions asked.

That guy over there who was just diagnosed with diabetes at age 20? He’s 26 now, and about to be dropped from his parents’ insurance, but he’s not worried. He can go online, head over to Insurance Exchange Central, and shop for his own individual policy. He’s still in school and not making much money at all, but not to worry, because his costs will be covered by some significant government subsidies so that he can still afford his syringes, insulin, test strips and other needs.

This young man fights with his desire to be free of his diabetes and the daily knowledge that his lifestyle has to be adjusted to live with it. Because his doctor is part of the community health center down the street, he’s able to check in often and work on some wellness initiatives to help control his diabetes and accommodate his lifestyle. The particular young man I’m thinking of loves to ride his bicycle, and tries to ride 20-30 miles per day. The exercise helps keep his glucose levels down to manageable levels, and the meter he uses sends daily glucose reports to his doctor via his wireless phone. His records are electronic, so when he travels to bike races in other states his medical history follows him in case he needs treatment.

This is one example of what will happen when health reform passes. No more exclusion for pre-existing conditions. Electronic health records. Focus on wellness instead of sickness. Streamlining Medicare. Government subsidies to assist with affordability.

Bottom line: We embrace everyone’s health as a national value, whether they’re healthy, diagnosed with an illness, are young, old, rich, poor, or middle class, employed or unemployed, artist or entrepreneur. Everyone.

This, and only this, justifies passing the Senate bill. When the other benefits are factored in, it is clear it’s well worth passing and should be passed. Right now.

There seems to be a lack of understanding about the difference between the terms exclusion and rating for pre-existing conditions. So let’s clear it up.

Pre-existing conditions in today’s terms

• Insurers may deny individual coverage based upon any pre-existing condition, and not only coverage for the condition itself, but anything they deem to be related to that condition that arises later on.
• If person has been uninsured for more than 6 months and is hired by an employer with group health insurance, the employer’s insurer may exclude that person’s pre-existing condition from coverage for as much as a year.
• Once that 12-month waiting period is satisfied (and again, this only applies to group health insurance plans provided by an employer) the insurer will cover the condition, but also ‘rate‘ the policy; that is, charge the employer more than the standard rate for all employees because some employees have a pre-existing condition.

Right now, today, insurance is not available to anyone with a pre-existing condition at all, unless they are hired by an employer, wait 12 months, and their employer isn’t priced out of the market altogether by a pre-existing condition.

Pre-existing conditions if health care reform passes

• No individual may be denied insurance due to a pre-existing condition, whether in the individual market or group markets.
• Insurers will have the right to charge 1.5 times the basic rate to smokers and up to 3 times the basic rate for age.

This is the change: There is no exclusion for a pre-existing condition. The insurer is limited as to the amount that can be charged for the policy overall to a multiple of the basic rate.

Wait, I thought the President said pre-existing conditions would be gone with health care reform?

This seems to be the disconnect. There appears to be some objection to the idea of rating higher-risk insureds, and that is being blended into a message that pre-existing conditions are still an issue in the Senate reform bill.

Not so much. There are two ways to approach the cost to cover everyone without regard to their health or lifestyle. The first is to take the whole pool, spread out all the costs and divvy it up equally without regard to age, health, or lifestyle. A single payer system would do it this way. The problem with that approach if you’re a 20-something is that you might not be all that thrilled to be paying for the costs of those 50-somethings in the pool.

The second approach is to “rate” the pool according to some objective criteria. Cover everyone, but charge more to groups that represent higher risk to the group as a whole. This is how the Senate bill approached the issue of costs.

Discrimination is an access issue, not a cost issue

Shutting the door in someone’s face and telling them they need not apply because they were sick once is discrimination. Opening the door and welcoming them in with a higher ticket price is not discrimination when the ticket cost represents their share of the cost of maintaining the pool.

It’s false to suggest, as some have, that ratings represent discrimination. For individuals with pre-existing conditions, it is a question of whether they put everything they have at risk, including their health, because they cannot afford to get decent health care on their own. Opening the door and allowing them to get something they cannot have right now ends discriminatory access.

Costs are a different question. We first have to establish that we value sick people at least as much as well ones. Then we can look at costs and whether ratings make sense or not.

This is a personal story that starts out scary but has a fairly happy ending.

I’m quite certain the ending would not be as hopeful were it not for the healthcare benefits available to federal employees, elected federal officials, and their families Even with those benefits, the ending may still not be so favorable under the current models for “managed care, if not for the other life experiences I am about to share.

I survived a spinal cord injury in 2003 and I’m very fortunate that it was not the kind of spinal cord injury that leaves a person permanently paralyzed. I did lose my ability to walk for a period and I was unable to use my hands for awhile, except for balancing things with assistance from my thumb and first two fingers. Obviously, I couldn’t drive so I was totally disabled and unable to work at any kind of job. Fortunately for me, my job as an Environmental Public Health Specialist came with Long Term Disability insurance as part of the compensation package. It was a State government job. Such compensation keeps government agencies competitive with private employers or I would never have accepted a government job back in the 1990s.

The private company I where I worked prior to that as a Research Scientist also included LTD insurance as part of the compensation package. The drawback of working for that company was a very lax attitude toward routine safety precautions and OSHA requirements. While that wasn’t true for most of that company, I had transferred to a department where that had been the norm. So I was quite happy to leave the private sector to become a government specialist in environmental public health!

I’m not a young woman, so my professional background is quite diverse. That has turned out to be a fortunate thing with regard to my recovery from the spinal cord injury. I majored in chemistry as an undergrad, financed by grants and scholarships. To supplement that other financial aid, I was employed by Washington University as a part-time Clinical Chemistry Technician at St. Louis Children’s Hospital. For about 3 years after graduation, I worked at a research institute as an Associate Research Biochemist in neurochemistry and neuropharmacology before deciding to pursue a Ph.D. in Biochemical Pharmacology at the University of Missouri-Columbia. This experience in the 1970s gave me a lot of exposure to what healthcare delivery was like before the era of managed care.

The next few paragraphs will sound like a sob story. It is not. It all ties together as a perspective of how the current healthcare system in the US has evolved into what it is now with a possible solution for the current US Health Crisis.

In 1980, job prospects for Ph.D. pharmacologists and biochemists were becoming dismal. Two weeks into my first semester in the graduate program, the Chairman of the Pharmacology Department informed us new students that he and his large, esteemed research team were transferring to another university. So his team, a third of the department, left. Another third of the department took his offer to transfer with him as a bargaining chip to land better jobs elsewhere. None of the entering graduate students followed him, so we all wanted to work with the remaining professor who was reputable and had funding.

That one professor happened to be the main reason I had chosen this program, along with the fact that I would be living only two hours away from my aging parents. First semester was tolerable but financial aid on this campus was not what it had been in St. Louis. That made the second semester terribly difficult and, besides that, my elderly parents were beginning to have major health problems. So I left the Ph.D. program.

That year was not a total loss. I was still able to complete enough work in the research (non-classroom) part of the program to be included as third author on what would turn out to be my final scientific publication for a major medical journal. Things I learned in the course of doing that work would turn out to be helpful when my own medical crisis occurred in 2003.

After leaving graduate school, I took the registry exam from the American Society of Clinical Pathologists to become a licensed Medical Technologist in Clinical Chemistry. By doing that, I thought, it would be more likely that for the rest of my career I would be able to work where I wanted to live, rather than live where I could find work. I decided to stay in Columbia and work in the Clinical Pathology Lab. at the local VA Hospital, where I met my husband. I’ve done other work since then, some related to medicine and some not so much. One job included scientific/medical analytic instrument sales, which added another dimension to my knowledge about healthcare costs.

The reason I’ve included the detail up to this point is to highlight part of my experience with the inner workings of science and medicine. Of value is that I was able to see how it all worked together, ultimately for the benefit of patients prior to the mid-1980′s.

After the early to mid-1980′s, things changed dramatically. There was no such thing as a degree in Hospital Administration prior to then. Medicine was not a “for-profit business” and pharmaceutical companies didn’t subsidize medical schools and graduate programs in the medical sciences like they do now. The Clinical Laboratory Improvement Amendments of 1988 (CLIA) enacted by HCFA (the Health Care Financing Administration) were not yet in existence. Life in the clinical laboratory, as well as everywhere else in medicine, changed dramatically when CLIA was enacted. In my opinion, the change was not for the better in terms of patient care.

Lucky for me, all of this prepared me for dealing with my current health challenges. I had become familiar with how the existing healthcare system worked and had the opportunity to watch it evolve to the mess it is now. I gained sufficient scientific and medical knowledge to know what treatments should be available and, more or less, how to raise hell when it wasn’t being offered. I had enough of an understanding of biological systems to know that patience, perseverance, and a positive attitude are needed to allow modern medicine to work its magic.

Also lucky for me, my husband and I changed our health insurance after I left my job as a Research Scientist for the private contract R&D company where I had been working in the early 1990′s. We’d each carried our own individual coverage through our employers prior to that but we decided it was a good idea to add me to his insurance policy at the VA. His was the same kind of policy that I’d had when I worked at the VA after graduate school but, with me added, it was a Self-and-Family plan. There was no waiting period for any pre-existing conditions, had I had any when he added me to his health insurance policy. The small, additional cost was the same for adding just a spouse or an entire family.

The trauma of sustaining a spinal cord injury comes with an array of problems, some of them medical and some of them not. Neurosurgeons don’t work cheap, but I was not even required to pay a co-pay except for my initial consultation. Neurosurgery, MRI’s, CT’s and physical therapy are not cheap, yet all of that was covered up to a point. Any “additional” physical therapy required a $15 co-pay, same as a doctor visit. This year, our co-pay has increased to $20.

Neuropathic pain is something that goes with a spinal cord injury all through the recovery process and, possibly, beyond. Traditional medicine can only do so much but non-Western medicine has its own magic. Acupuncture helped me to a great extent and it was covered by our health insurance through the VA. The acupuncturist I chose was not on the list of preferred providers, so I was reimbursed 60% for each visit.

Had I known which ones were on the preferred provider list, I would’ve paid $15 for each acupuncture visit. Physicians (MD’s and DO’s) who weren’t on the list would have been reimbursed at 80%, but I’ve only encountered one physician who I ever wanted to see who was not on the list. The only reason he wasn’t was because he had plans to retire the following year so he didn’t fill out the paperwork to be included for that final year he was my doctor.

The VA (Department of Veteran’s Affairs) offers its employees the same health insurance offered to all other federal employees under the Federal Employees Health Benefits (FEHB) program. There is an array of health insurance companies who choose to participate and, as far as I know, any insurance carrier is eligible to bid on being included in the FEHB plans offered to federal employees every November.

Both HMO and Fee-for-Service plans are offered. HMO plans are usually more restrictive than Fee-for-Service plans in different ways. This year, there were 43 pages of HMO plans offered and 18 Fee-for-Service plans for each of the thousands of federal employees to choose from. The HMO’s are regional plans with specific service areas. That partly accounts for the fact that there are pages and pages of them. The Fee-for-Service plans are all available nationwide or, in some cases, world-wide.

Another caveat is that not all federal employees are created equal. Postal Employees are charged lower premiums but have the same selection of health plans. Federal employees working for the Foreign Service have some benefits not available to most others. Members of Congress and their staffs have a similar but different set of benefits that used to be more clearly outlined than what’s immediately apparent on the FEHB web site now.

The good news is, the structure for “universal” health insurance exists and it’s NOT a single-payer system. There is no waiting period for pre-existing conditions, at least not with the plans my husband and I have had. It doesn’t exclude any insurance company that is willing to meet the requirements to compete for the large pool of federal employees. Adding the rest of us would only increase the size of the pool and SHOULD lower the premiums paid by all insured individuals.

The bad news is that costs are still rising. Healthcare providers who remember how things were prior to HCFA are retiring. Insurance companies had a big hand in writing the HCFA regulations and continue to be the “experts” consulted when writing new legislation. Pharmaceutical companies are staffed but not run by medical researchers and those who worked for them prior to HCFA are also retiring or being given “golden-handshakes.”

One challenge is that youthful experts have never known healthcare delivery to be any other way than how its been for the past 20 years. Another challenge is that greedy players who know how to game the system are in the best position to have the most influence.

The BOTTOM LINE is that the infrastructure for first-rate healthcare ALREADY EXISTS for those insurers and the uninsured or under-insured who desire to participate. Our job is to do what we can to remove the barriers that prevent it from being available to the rest of us.