by Steve and Timothy Imholt (mainly Steve, Tim was too angry, as he is an adult with autism and has an autistic son he pays out of pocket to cover.)

Do you remember the debate about why Obamacare was going to be so very good or so very evil (depending on who was hogging the microphone)? Regardless of where you fell on the scale from progressive to arch conservative, one area which had very little argument was over what healthcare should cover regarding children. Yes, there was argument about the role of government, about government over reach, about fiscal consequences, but about kids?

Nope, I don’t remember it.

I bet you don’t either.

I can remember the discussions about orphan drugs. I remember comments from both sides about catastrophic coverage. Even discussions about pre-existing conditions. These were things that most people thought the ACA would/should (depending on party affiliation) cover. Even the insurance companies and the Republicans in a last ditch effort to stop the ACA talked about other legislation, in place of the ACA, that would cover pre-existing and catastrophic situations.

But what they didn’t do was talk about situations that were fixable when the fix was expensive. Talk about donut holes. There is donut hole in coverage the size of the Holland Tunnel if you work for most companies. You see, the way things are today, some kinds of illnesses actually ARE covered by the ACA marketplace and public aid, but NOT through employer plans precisely because they are so expensive, and the employers had good lobbyists to get wording in there for an exemption for employer based plans.

Still others aren’t covered by the ACA market place OR the employer because get this… they are too expensive. It’s like finding a Ho Chi Minh tunnel at the bottom of a Florida sized sinkhole. You take the tunnel because you have to.

Is there a poster child for this hole? Autism.

You see, when you catch autism early it is treatable. But the treatment needs to be aggressive. And even better, its effects can be truly managed and even called cured. But the current costs are somewhere higher than $30,000 and in some cases even $50,000 per year for several years. Most employers would rather not have to deal with that kind of cost. And (please use a Gomer Pyle voice when reading this), Surprise, Surprise, Surpirse, state and federal laws say they don’t have to cover it.

Think about this. The employed person has to pay out of pocket to get his kids treated. That same person has to pay taxes that, in turn, pay for subsidized coverage for other people, some of whom don’t have a job, so that their kids can get this treatment because the ACA says that they can. So one guy gets to fork out the money twice, or if he can’t afford for his kids to get these treatments out of his own pocket has real problems.

That is assuming the guy who has a job can find a way to afford it. How many people have that kind of money leftover from the rest of their budget in their after tax salary? Especially with all the new tax rates, hikes in grocery store prices, and stagnant wages in the middle class.

It is a nutty situation, but that is just one prime example. We are SURE there are others. We will be on the lookout. Just follow bankruptcy filings and some will likely be found.

The ACA act itself provides a partial loophole as well. Turns out the Fed doesn’t always cover it because it’s a congenital condition. Those plans which do cover it are a lot more expensive. Currently, the only real option left for a family with an average income is for the kid to get put on public aid. On public aid, the kid can get covered. Except that like a Ho Chi Minh tunnel, the hole can collapse at any moment.

Now for those readers who don’t have to deal with this every day, getting on public aid is NOT like switching cable companies. You need to get qualified again, and again, and again. It takes a lot of effort by parents to pull it off. And each time they have to requalify, treatment gets impacted either because docs won’t accept it, or they can’t actually deliver until approved (again and again and again).

Remember that comment about catching it early, and being aggressive? Let’s be blunt. Being aggressive is not compatible with government paperwork.

So, as a country, we end up actually causing kids to not get the treatment they need, exactly when it would do the most good. All because companies didn’t want to have this really large cost, and the Feds on ACA didn’t want the premiums to go up even more than they are going up next year.

How did it get this way? From my perspective, it was because from the progressive standpoint, it had to be covered, so sticking it to the states was a good idea. (Actually for some of the progressives, anything that eventually will lead to a single payer system is a good thing, no matter how many kids get trampled in the meantime). But the conservatives aren’t off the hook either. Again, from my standpoint, allowing companies to exclude this kind of thing, is the direct equivalent of being Pontius Pilate, washing their hands. Why? Because for conservatives, anything that shows how bad the ACA is must be good, no matter how many kids are trampled.

From my perspective, political autism has eradicated public oughtism.

The saddest part of all? It’s not those kids knowing that they won’t be treated today. You see, none of them will notice it today because they are too young, and they really do have issues. And it probably won’t be those kids when they are grown, because at the speed they won’t get treatment, they will have challenges, at a much higher rate than they should. And the annual cost of that will be paid by everyone, just as the ineffectual treatment they will get because of a defective public aid system.

Yet keep sending these yahoos back to Washington, again, and again. Perhaps it’s the public who is more autistic than we would ever want to admit.

Nicholas Angel: How could this be for the greater good?
Neighbourhood Watch Alliance: [all together] The Greater Good.
Nicholas Angel: Shut it!

Hot Fuzz 2007

Autism is a disorder, really a neurological condition that is typically diagnosed early in childhood that is characterized by huge difficulties in communication and forming relationships with other people. These challenges are due to the way the people with this condition use language and interpret abstract concepts.

My son is a four year old on the autism spectrum. He sits in the mild side, and has been in treatment for a while to treat his various developmental struggles. He is far from alone in these struggles. The autism spectrum is a wide range of severities of this disorder but it is said that more than 1 in 100 kids (more like 1 in 88) sits on the spectrum and requires some kind of treatment. These treatments can be shockingly costly.

Many of these treatments have been covered by our insurance company as every therapy he has been in was prescribed by a medical professional. He has been to neurologists, speech therapists, occupational therapists, all kinds of stuff. The co-pays alone would boggle your mind.

Then we come to today. He goes to one of his two regularly weekly scheduled speech therapy appointments that, until this week has been covered. The health care provider puts in an authorization request for treatment before his appointment (as is their normal procedure), and it is denied. That is strange, why now, why not a week ago?

Something strange is afoot at the Circle K you say?

Wait for it, this gets worse.

It turns out that under the Affordable Care Act they, according to the insurance company, they are required to only cover these types of therapies for “restorative reasons.” What is a restorative reason you ask? They can cover more but it is at their discretion. So, what company would do so if they don’t have to? Well certainly not this one.

Put another way if he had been in an accident and lost the ability to speak they would help, otherwise they won’t. Autistic kids are out of luck I guess, at least to go through a qualified private insurance covered speech therapist.

I was angry for a variety of reasons mostly because this is landing on us with no warning.

So, I asked, what is going on? When did this change?

Oh a letter was sent out 3 days ago? On Friday, and today is Tuesday? Nice, I guess I haven’t gotten or read that yet but ok.

I asked the question, what are these kids supposed to do? Have no shot in life? Medical professionals can prescribe a treatment and unless you can afford the $250-$400/week in cost out of pocket your kid is just out of luck?

No, that isn’t the case, the insurance company representative says. I can appeal (which they told me would in all likelihood be denied but I can do it), or I can go to the local school system department of special education.

So let’s review:

  • Covered last week not covered today
  • Costs of my policy go up year over year
  • Out of pocket just increased by at least $1000/month for a procedure prescribed by a medical professional (and that doesn’t include all the increases in copays elsewhere).
  • Coverage is shifting away from treating those with diagnosed disabilities, sort of.
  • Because of his age he might be covered merely by an already overspent public school system according to the insurance company (the school district disagrees).

Put another way the ACA through some convoluted process just shifted what should be a medical procedure onto the school system?

I guess they wanted the federal deficit numbers to look better for the kids they have to cover through the subsidies? Could that be the case? Surely not…No, they would never forget to tell the whole truth right?

Does that seem like how things are supposed to work?

It appears as though we are playing a shell game of which part of the government goes into debt to do the job it was design to do. Also this brings to mind what qualifications the school system has to do therapeutic treatments that should be done by someone trained specifically for this purpose. Or is the Department of Education just working its way into all aspects of our life so that it never gets cut back and only grows?

Whatever the reason is this monstrously large bill that was supposed to bring down costs is certainly having issues proving its worth beyond some kind of procedure requiring a band aid or the most cursory of treatment.

As an interesting PS to this story. I was on twitter venting about this and got pounded by several people from one of the two major political parties. One statement said, basically, I didn’t get it and that it was all for the “greater good.” Another insane defender of all things done by one party said that, essentially, not that long ago no one got anything.

The “no one got anything” statement is interesting because instead of fixing the problem by making sure everyone gets something we are stripping coverage on an obviously pre-existing condition and blaming corporate greed. I am my wits end with the partisan garbage. We no longer care about solving problems in this country merely about assigning blame. We do this while parents have to figure out how to help the very small children that we are supposed to be doing all of this to help. I will find a way to make sure Emmit gets what he needs, but it sure would be nice to be able to keep the coverage I liked, without that price going up yet again or coverage being reduced even further, but I can I can keep my doctor if I pay for it out of pocket while paying the insurance company to do less with more.

I guess we hoped, and we got change.

Tim I. PhD

-Author of the bestselling novel Forest of Assassins

Amazon.com Widgets

Update:  DTG:  “The Greater Good” Boy that argument sounds familiar:

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by Timothy Imholt

For anyone who has read my blog posts you know I have opinions that really don’t fit with either of the two major political parties. I sit in a zone that is forgotten about largely called the common sense zone, and there is no place for that in government.

I have the Uncle Steve Imholt who recently retired. He spent multiple decades as a software engineer before becoming a software engineering manager for very large programs. He is no stranger to figuring out budgets, costs, and weaving his way through government forms. I should point out that many of the software programs he managed were for government contracts. The point is, if he can’t navigate through the hurdles of a Healthcare exchange program, who can?!?!?!?!

I got this email from him recently that made me wonder how we are all going to survive the “Affordable” Care Act Rollout. I won’t render any opinion on this entire healthcare law other than to say two things. There are some aspects of my family’s life that were once covered that now aren’t. The other is that the Allied Forces defeated Hitler during World War 2 in much less time than it is taking to get this healthcare exchange fixed.

 

Here is the emails, titled: NOT HAVING TO WORRY ABOUT PAYING FOR HEALTH CARE COULD END UP KILLING ME.

 

It’s April 14, 2015 and I’m still struggling to finish my taxes. Why? Because I stopped working in September 2014.

I suppose you could call it retirement. But retirement wasn’t supposed to be so much like working.

You see, after working in IT for a long time. A good chunk of that was in health care, in both hospitals, and in the insurance side. So when 2014 hit with a ton of medical bills and retirement, I decided to itemize my health costs on my tax return. That meant I had to pull in a load of different documents from my company health savings account, the amounts I had to finance for my dentures, and about 19 different kinds of medical bills and payments. As I’m plowing through this I’m thinking, Thank God, I left COBRA in December and for 2015 only have Coventry obtained through the Healthcare.gov website.

You say so what? Well you’re going to hear the rest of the story.

I enrolled in the health coverage back in December to begin January 1. At that point, I wrote an email to the marketplace and attached a copy of my separation doc from employer saying I ended employment in September. In the email I said I believed my income would be about $70K for 2015 (a highly optimistic estimate). Using that figure the site came back with a really substantial subsidy. Still not sure how that happened, but what the heck.

In January I get a letter from the Health Insurance Marketplace saying I had not supplied sufficient documentation to justify I was earning only 70K. Actually I was unemployed until mid-February when I took a part time job because I needed to do something (retirement isn’t coming easy to me). I did the part time job for a couple of weeks but frankly, it was a lot more physical than I had originally thought. So I stopped working that and we (the wife and I) applied for early Social Security. So I used that information to send back an updated list with my pay stub from the part time job. I also indicated I thought I would be getting income as I needed from my IRA, to get me up to the 70K. This runaround eventually resulted in a long set of phone calls to the Marketplace to get my records updated – again.

I was told we were good to go.

Anyway, a week ago Friday, my wife gets notice from Social Security that her benefits would start in April for March (only the government can tell you in advance how much you are going to get for the past). Then Monday the 13th I get a call from the Social Security Admin asking why I wanted to delay getting my SS payments until April. I told the nice lady that I’d take them as soon as they could start them. While I may be dumb, I ain’t stupid.

So now I get to Tuesday. At 7PM on Tuesday I get an email from the Healthcare marketplace that I had failed to provide proper documentation on my income so I was no longer receiving the subsidy effective May 1. It was immediately followed into my in basket with an email stating that because of my recent application I could apply for benefits through June 15.

My initial reaction was HUH??? It was followed by lots of words, most of them unprintable, a few unintelligible.

I went and got a drink. Uncle Sam would have to wait until tomorrow for my taxes.

***

It’s now 3 AM on April 15, and I can’t sleep. So I get back up, finish plowing through the remainder of turbo tax and finally about 6:30 AM have them ready to e-file.

I go down, tell the wife, I think we are good to go on the taxes, but the health care was still a FUBAR.

I then make some coffee and spend a couple of minutes with my grandkids.

I decide it’s time to tackle the Health Insurance Marketplace emails. So I call the folks in London Kentucky. The support person after figuring out who I was, started looking through my files and decided that yes there was indeed a problem. She should get credit for keeping me from just starting to whimper in submission to the government.   As she worked to figure out what had happened, it dawned on her and I that the SS payments that my wife was going to get was the reason our coverage had gotten s rejected.

She basically said, this was going to happen all over again, when they received word I was going to receive social security.

I decided to let that problem wait. But I did log back into the health exchange to see that my new friend at the exchange had emailed me to say I had until June 1 to get everything fixed.

I breathed a sigh of relief.

On Thursday morning I got an email from TurboTax saying my tax return had been rejected.

I tell you that this whole thing about Obamacare cutting the cost of health care is true. I’ll be dead long before I should have been making it work.

 

Why did I want to air this publicly? I see no end of ads coming in the next election cycle about all the smooth rollout of this health insurance exchange system.

If this is smooth, I would hate to see bumpy.

 

Timothy Imholt is the author of several novels, including the newly released book THE FINAL WORLD WAR, written around the premise that Iran does get nuclear weapons and decides to use them in the fashion they have openly stated they wanted to.