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Insurance Companies Should Be Held To The Same Standards

By Dr. Zaneb Beams

“A minimum Medical Loss Ratio (MLR) is a requirement that insurers spend, at least, a specified percentage of  premium dollars on medical care rather than on administration, marketing, and profit."

Today I want to tell a story about the “MLR” as it is nicknamed.

About a year and a half ago, my office manager, (let’s call her Lucy), whom I’ve known for 26 years, stopped breathing and turned blue at home, late at night. Her husband did everything right. Called 911, started CPR. EMS arrived and continued CPR, finally got a pulse and spontaneous respirations. Dashed to the county hospital where my manager, stubborn as she is, stopped breathing again. CPR was performed and she seemed to stabilize for a few minutes. Apparently this happened 5 times before they finally placed her on mechanical ventilation, stabilized her, and moved her to the ICU.

When it comes to her health, Lucy has not been so responsible. But when it comes to her work, she is impeccable. She is your classic middle class, hard working, American. She worked as a manager in retail, had to bring the bread home so went back to work over the Christmas holiday when her first child was three weeks old, worked two jobs to pay health bills for an ill husband while raising her two young children, never misses work, goes to church, raises a garden, etc.

In a shockingly ironic and silly turn of events, her health insurance lapsed three months ago. This was a policy purchased before the ICU stay with the 5 Code Blues. No problem, you say, due to the Affordable Care Act (ACA) Lucy can not have her policy rescinded because she cost too much for the company. They can’t reject her due to any of her pre-existing conditions. But, her fear is, they CAN charge her through the nose to reinstate her policy, or purchase a new one.

This is why protecting provisions regarding the MLR, as arcane and mundane as it might sound, become crucial. Medicine is in a strange limbo land when it comes to capitalism and profits. Folks want the best and most cutting edge care but it doesn’t seem fair to many of us to profit inordinately off their suffering. Certainly we, purveyors of wellness, work hard and help people every day and we all know it cost a lifetime of savings to get our educations. But at the same time we as health care providers are held to some standards of quality and cost. We can’t, for the most part, go around charging hundreds of dollars for a simple office visit. Because we would be the object of outrage.

Until recently, somehow, health insurance companies were allowed to do this. It’s a free market right, so they can charge what customers are willing to pay? Right? Hopefully, not anymore. As a result of provisions in the Affordable Care Act, insurers will be allowed to continue to reap record profits but they will also be asked to spend a reasonable percentage of revenue on actual care as opposed to “administrative costs” (read: bonuses and salaries for CEO’s).

What does this have to do with Lucy, you’re wondering? Well, Lucy is in a panic of sorts because she wants to be responsible and purchase health insurance on the individual market but is terrified of being unable to afford the insanely high premiums she predicts they will assign her due to the “5 Code Blue” event, her “pre-existing condition”. Maryland has a clear commitment to strong and thorough implementation of the ACA, and I hope for her sake, the federal law is not repealed. If ACA is repealed, Lucy will be living day to day, hoping she doesn’t get sick and go bankrupt because health insurance companies are exempt from the reasonable regulations we, their fellow merchants of wellness, are held to.

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