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System needs an overhaul

| June 8, 2010 9:00 PM

Sometimes outside and otherwise random events converge in the mind, leading to an internal course of thought that can broaden perspective. Not so much an "aha!" moment as it is like a puzzle; pieces which, once connected, form a more cohesive picture.

During a recent visit with family we heard the story of a young American who just returned from a year teaching English in South Korea. While there, symptoms led to hospitalization and the news that he has cancer. He needs long-term, aggressive treatment to have hope of surviving.

Because of insurance rules, he was faced with a dilemma: Stay in Korea where he could get free, high quality (by his description the hospital is "nicer" than those here and the staff fantastic) care alone; or come back here to have the comfort of loved ones nearby, but where he is now essentially uninsurable due to the "pre-existing condition" diagnosed out of country. He came home, but his family cannot afford even the annual tens of thousands for his medicines, let alone in-hospital treatments.

His story is a compelling argument for a public health system. On the other side of the coin are concerns about cost and perceived inefficiencies.

As I listened to presentations during an SSI/disability law seminar last Friday in Moscow, it occurred to me: When we consider costs, we must factor in everything involved (agency staff, attorney/litigation costs, court resources, administrative costs) in making and - inevitably - appealing these claims.

A few illustrative points:

• Based on results of an FOIA request in Idaho, the time paid staff spend reviewing initial SSI/ disability claims to determine eligibility averages only 20 minutes (even for large files of medical records); the vast majority are thus denied.

• There are three levels of internal appeal before getting to a district court; 95 percent are denied at the first level.

• Courts then overturn 62 percent of those denials. This process takes about two years and attorney assistance.

• With regard to Medicaid nursing care for the elderly/disabled, while the average person is generally eligible due to legally "excluded" assets (e.g., home, car, certain spouse's assets, etc.), the agency does not inform applicants of these entitlements, so most "spend down" to meet perceived requirements, divesting themselves of lifetime savings and accumulations. It is, but shouldn't be, thus necessary to hire a lawyer to know the agency's rules which benefit claimants.

Eligibility determinations for public health assistance also include many inconsistencies and absurdities. Real-life examples include denials citing the ability to make a sandwich (thus allegedly able to take care of himself), do a little gardening (therefore a light labor job is believed possible), or walk a block (but not asking how long or with what difficulty), regardless of other evidence of limitations.

In another example, a former stay-at-home mom who seemed able to work was determined eligible for benefits in part because she had no work experience. This isn't the whole story of course, but in short, the decisions are often arbitrary and sometimes ludicrous. Some are designed to prevent fraud, but operate to prevent eligibility or even encourage abuse.

This is just a glimpse of a complex, time-consuming, inefficient and expensive eligibility process which would be unnecessary if we do end up with universal public health care. That's only one factor in the analysis, but must be included in assessing comparative costs of our current system.

The determination has a threshold constitutional, if not humanistic, argument: Does the right to life include the health care to secure it?

Sholeh Patrick, J.D. is a columnist for the Hagadone News Network. Sholehjo@hotmail.com

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