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Getting Health Care and Keeping Your Privacy

Merrie B. Weiss

No matter how much preparation and preventative medicine a person invests in, an accident or unexpected illness can make a trip to the doctor necessary. But if you're the sort who doesn't like all the nosiness and forms that generally go with such outings, what options do you have? Can a person get decent medical care without being in the system? What can a person with a chronic medical condition do to try to minimize the threat to their privacy and security that health care poses nowadays?

It ain't easy to do this, that's for sure. Although Clinton's socialized medicine plan was rejected out of hand, he and other do-gooders have been busily working to institute it piecemeal. And although the NID as a whole appears to be temporarily stalled, databases are being built with great speed. Besides, we already have a national ID number; it just isn't called that yet.

The medical care system has become increasingly bureaucratized from the 1970s on, with insurance companies appearing to be happy accomplices to the process. The result has been huge increases in prices, less competition as "managed care" and other impersonal systems and laws have made medical entrepreneurship increasingly challenging, and decreased quality of care as trained medical professionals have their decisions questioned--and often overturned--by some bean-counter in an office thousands of miles away. All this has also led to a shift in the type of person who seeks a medical career--away from the genuine, caring person to those who see it as a fairly secure way to earn lots of money with less effort than it used to take, or those who enjoy having power over people's lives.

The medical system is broken, and will get more broken before it is fixed (look at Canada as a harbinger of what we may be in for... not a pretty sight).

So, how can you get what you need out of the system, without giving up too much of your personal information?

Bye-bye insurance

Many of you are going to cringe at this, but the first thing that needs to go is your insurance. It's almost entirely SSN-based, and therefore a big fat pipeline into your medical history and scores of other databases. Why continue to feed into that pipeline? That albatross should be enough to cause you to think twice about insurance, but there are other very good reasons to say bye-bye to it.

Health care insurance, just like auto insurance or life insurance, is a bet you place with the company on the odds of certain events happening--an illness, accident, or disease striking you, in this case. You pay in to the company on a regular basis, and if you ever need your policy, you'll be "covered" for your medical expenses. How nice of them... right? Hardly. Insurance companies are for-profit businesses. By definition, they take in more than they give out, like a casino--not good odds for a healthy person. They make their money off of people who pay in and don't use the services they’re paying for, and by cutting the costs of the services they do cover as much as possible. Look closely at how much they actually do cover in the policy, and how much you’re expected to pay. Even thus informed, you may be in for some unexpected surprises when you try to use your policy. For example, one state I lived in mandated that women's annual gynecological exams be covered by insurance. My insurance company promptly switched their coverage from 80% of the entire office visit to covering the full cost of the PAP smear and interpretation only--a huge savings for them.

It'd be well worth your time to pull out your health insurance policy, read what's covered and what isn't (as well as the terms for qualifying for coverage--I know a family who had a huge surgery and cancer treatment bill refused by their insurance company simply because they didn't notify the company within the 48-hour time period the policy mandated), and do some calculating. How much of your salary is deducted for health insurance premiums? What does that come to annually? Now look at your actual health care expenses for the year. Add up what the insurance covered as well as your out-of-pocket payments (co-payments, deductibles, and non-covered items). If it's less than what you've paid in, you're losing money on the insurance game.

I know, I know... "But what if I get cancer or some other awful disease?" It's a scary possibility. But don't let the fear enable a financially stupid decision. You can fairly realistically assess your risks by looking at your family history and personal lifestyle. If cancer that's known to be genetically-linked is in your family (some breast and gastrointestinal cancers are of this sort), or heart disease is prevalent, you might want to keep your insurance. Or, you can buy a cheaper "catastrophic illness" policy that you use only if you get walloped with a major illness. If you don't have those risks, and your lifestyle is healthy (and it should be--anyone who values privacy does not want to be in a hospital), you'd probably be better off without coverage. You can take a portion of the extra money you'll be bringing home to invest in your own emergency medical fund.

Even if you have kids, medical insurance doesn't always pay off. We've been fed the scare stories so many times that even a sharp person can let these kinds of arguments twist their decision-making. Do you really need to have all those "well baby" checkups that insurance covers? If your child gets sick or injured, in most cases other options that work for you will work for your child. Educate yourself about vaccines and other "routine" pediatric care, so that you don't waste money--and risk your child's health--with needless procedures that are mandated out of ignorance and fear.

Insurance companies, always on the lookout to reduce costs, generally have oversight and doctor-review committees to look over patient charts and see if they can identify ways to streamline the care process and costs. What this means for you is that if you use your insurance to pay for a medical visit or procedure, all of your medical chart may be fair territory for these folks' busy eyes. Most of the time this information is kept fairly confidential, but lapses have been known to occur... and anyway, do you really want these people to know all the intimate things your doctor knows? If the current crop of ferals has its way, signing that innocuous-looking release at the bottom of the patient information sheet will mean that government databases, and in some situations law-enforcement agencies and other "official personnel" can access your files without your knowledge or consent. Cheery thought, that.

Last, having insurance doesn't mean that you'll always have it. As costs continue to rise, insurance companies are looking to decrease their risks. One way they do this is by culling high-risk groups from their coverage. If you have a "pre-existing condition" or a genetic risk for some disease, your coverage can be yanked. Once that happens, it's damn near impossible to get another company to even look at you--if one does, chances are the cost will be so high that the insurance probably won't benefit you. Better to be prepared and as self-sufficient as possible from the get-go. There are also ways to reduce your medical costs so that you aren't paying the grossly inflated "full price" for most of the services you require. More on that later.

Treatment options

Many people like the stereotype of the "family doctor" in whom one can place their trust and confidence. Having a physician like that is actually the best way to get high-quality medical care, too--your doctor will know everything you tell her about your body and how it works. Unfortunately, this situation is also the highest-risk for people who want to keep a low profile. Nowadays, a doctor's office wants to know your SSN (which they don't need to know; it's a convenience for them), and many will ask for your driver's license and promptly go photocopy it to have in your records. (Not having such documents on hand makes it much easier to resist their requests.) With all your records there in one location, it's very easy for nosy folks to go snooping and find all kinds of things about you that you don't want them to know. What alternatives do you have?

If you're generally healthy and see a doctor rarely, for severe illnesses, your best bet is probably what I call a "doc in a box"--the urgent care facilities that have sprung up as alternatives to clinics and emergency departments. These places are geared toward dealing with commonplace, fairly routine problems; they're good at providing care for minor injuries (sprains, burns, broken bones) and acute illnesses (flu and other respiratory infections) without a lot of question-asking. Their goal is to see as many patients as they safely can; if you don't volunteer a lot of information, they won't ask a lot of questions. Many people use them as a quasi-family doctor, getting flu shots and other preventative treatment there as well. It's fairly easy to make up a name (just don’t give that away with your behavior), fail to give a SSN, and get the care you need and go on. One warning: they do tend to call you for follow-up, so having some kind of strategy for dealing with that possibility is a good idea. In larger cities, many offices and competing doc in a box chains exist, making it very easy to go from place to place if needed.

Another option is the local emergency department (ED, more commonly known as the ER to nonmedical folks). The quality of ED treatment can range from scary (generally more likely in very small towns) to excellent (typically large city hospitals and university-affiliated training centers). Where the staff is good, EDs are better than doc in a boxes at identifying and treating unusual problems. If you've been traveling or have some other reason to suspect that your symptoms might be due to a rare disease or condition, it'd probably be worth the potential disadvantages of an ED to go there.

Because EDs are part of a hospital, they tend to have more paperwork and bureaucracy than doc in a box places. Many EDs, even in private hospitals, have systems set up to deal with indigent and uninsured patients, which means you may be shunted to a social worker whether you want to talk to one or not. Particularly in larger cities, many poor people use an ED as their "regular doctor", which can make the wait very long if your case isn’t a true emergency, and not especially pleasant. If the hospital is a teaching hospital, your case will be reviewed by several different doctors, and may even be featured in teaching rounds if you're unusual in some way. This doesn't mean that all those people will know who you are, but if you'd rather not have your medical problem become the "Gastrointestinal Stumper of the Week", you'd be better off going somewhere else.

For some types of routine care, another option is government clinics. These are generally set up to provide low-cost basic services to the poor, although many do not require proof of income before providing services. If you want vaccines or boosters, for example, this may be your cheapest way of getting them. I haven’t used these services and don't know the ropes for them, but it seems logical to think that because they're government-run, you need to have certain papers to get the health care you're seeking. If true, this would blow your privacy, unless you can fabricate a convincing SSN. Many people may find this suggestion immoral, but another way to look at it is that by paying the fee they charge you're only paying for what you use, rather than continuing to support the entire bloated bureaucracy. Even so, that price is heavily subsidized, so it's understandable that people wouldn’t go for this option.

If you have family or trusted friends in the medical profession, using them for care, or for access to care by others, might be an option you can try. Some people are more relaxed about caring for friends and family than others; if you can inquire discreetly before you need medical care, it'd be smart to do so. If you can be seen entirely off the books, so much the better; that's likely to be an option only if the doctor already knows and trusts you, though. If you're lucky enough to create such an opportunity, don't be stupid enough to blow it by abusing your friend's generosity, or by talking about it to others. Doing this kind of thing probably breaks at least a few feral and/or state laws, and you don't want to repay such a kindness with a bust that results in your friend losing her license.

Another approach to the issue involves rethinking the kind of treatment you want or need. There are lots of options available these days. Chiropractors, nurse practitioners, herbalists, physician assistants, acupuncturists, naturopaths, homeopaths, and other kinds of health-care providers offer different solutions to medical problems. Before pursuing these options, thoroughly check out both the type of care and the individual you plan to see.

Even within the typical medical approach, there are options. For example, instead of using an obstetrician and the full suite of hospital-based (and expensive) prenatal and maternal care, consider using a birthing center, or a midwife and having a homebirth. These options are generally less expensive, much more respectful of your privacy and rights, and for a normal pregnancy and delivery, they actually have fewer risks than a hospital birth.

In the digital age, lots of experts have gone online, offering advice to individuals; you may be able to get your health care question answered in such a forum. This won't substitute for treatment, of course, but it can help you take better care of yourself, and to know when you do need to see a doctor. In some states, physician assistants can see, diagnose, and treat patients; in others, nurse specialists and pharmacists can do limited prescribing of medicines. If you have a well-controlled chronic condition, using these people will almost certainly be cheaper than an MD.

If you need prescription medications, ask about free samples. Generally you can get at least a few doses. Pharmacies are highly computerized now, and almost always require a signature when dispensing medications; avoid giving your SSN. If your privacy is that important to you, it might be worth the higher financial cost to go to a small independent pharmacy rather than the big chains, many of which have nationalized record-keeping systems. Another option is online purchasing. Drugstore.com is one site that offers prescription services online. The process looks fairly straightforward and secure, and once you’re set up, getting refills is routine. One of the best features of this business is that they’ll deliver your meds to a street address or PO box. On the meds I checked, their prices are competitive too. Once you’re in the system, you can log in from anywhere to order a refill, or have your physician call in a new prescription if needed--no need to worry about transferring a prescription to a new pharmacy when you’re on the road. Recent feral hand-wringing about offshore sites that sell meds that are prescription-only in the US may result in all online pharmacies being forbidden to sell prescription-only meds, though.

If you want to take the risk, you can forego the prescription and check into the offshore pharmacy Web sites that sell to Americans; be warned that Customs takes a very dim view of this kind of "drug trafficking" too, and if caught you’ll be facing serious penalties. Another option is to travel to our neighbor to the south, and get your medications there. As almost all medications are "over the counter" there, they are cheap and fairly easy to obtain (but you may need to know the Spanish equivalent of the generic name of the drug--they don't have all the same brand names we do). If you do this, be smart, don't buy right over the border (where there are almost certainly going to be US ferals watching for such activity), and understand the risk you're taking. You could get searched on re-entry into the States, and if caught, you could get a jail sentence.

Payment options

As discussed already, using insurance is a really bad idea when it comes to keeping a low profile. The smartest option is to pay your bills with cash at the time service is given. That way there aren't any paper trails, and no bills to come lagging after you.

If you can manage this, the best way to describe yourself when asked for an insurance card is to say that you're "self-insured". It's a vague way of saying that you're going to pay your own bill, which could lead to the office offering various payment terms to you. Some hospitals and offices seem to equate "self-insured" and "indigent", so you might get some friendly bureaucrats a-calling... If you're so inclined, you could play cat-and-mouse with the do-gooder, and keep him from bothering other people. Perpetuating the idea of some degree of financial hardship can pay off, though, in terms of getting samples of meds and other discounts.

Medical costs are so high in part because of all the paperwork and personnel involved in coding, billing, and dealing with insurance. Many doctor's offices now have more staff involved in these tasks than they have doctors! If you can keep these costs down, very often the office will be happy to cut you a deal on the bill. Ask about this in advance if possible. They might offer a cash discount, or "the Medicare price", if you can pay your bill the same day you're seen. The Medicare price is generally around 40-60% off the usual fee--a hefty savings.

If you can't swing the bill on your own, it might be worth borrowing from someone in order to get these savings. Failing that, you might be able to negotiate a smaller discount if you pay in full before the next billing cycle. If that doesn't work, virtually all places have some kind of payment plan--some don't charge interest, while others (hospitals seem to fall at this end of the spectrum) charge interest rates that rival credit card rates. If you need to set up a payment schedule, don't automatically accept their suggestion; ask about other options, and be sure to ask if there's a prepayment penalty. It's better to set up a repayment amount you can easily handle and then prepay to minimize your interest, than to set up one you might not be able to meet. In general, hospitals tend to be more rigid about payments, but even so, it doesn't hurt to ask about ways to minimize your expense. Many hospitals and clinics (and even some doctors' offices) are set up to be able to "write off" a certain amount of their billable accounts as charity. If your expenses are huge and you genuinely have no way of meeting the obligation, you might want to pursue this option as a last resort. To do any formal application for such services, though, you may be required to supply your tax forms and other financial records. (You may also want to make sure that the write-off is covered by private donations rather than government subsidies.)

If you have a skill or service that is valuable, you might be able to barter for services, although the days of trading chickens for medical care are long gone. Most offices aren't set up to handle this kind of payment, so it's very unlikely that hospitals and clinics will be interested; even larger doctors' offices might not. If you want to propose some kind of barter arrangement, ask the doctor first, and try to get him on your side; that might be enough to persuade the accountant or bookkeeper to go along. In smaller doctor's offices, where they tend to be more flexible, you might have better luck, but even so, this is an unusual tactic and you should be prepared for resistance. If you're a regular patient, bring it up from time to time, have examples of other cases where it's worked for you, and you might be able to persuade the doctor to give it a go.

Getting medical care--even good medical care--is possible without being fully in the system, at least so far. Your odds of doing so are highest if you are already in good physical condition--which means taking responsibility for your health yourself--or if your chronic condition is well-controlled, and you know what to do when problems do arise. It does require some effort, and may involve choices you wish you didn't have to make. Nobody ever said freedom and privacy were easy... and if current trends continue, medical privacy will be harder and harder to come by. Having some kind of plan--including preventative care--is important, so that you can avoid the ever-watchful eye of Big Brother as much as possible. Good health is too valuable to jeopardize because of the intrusive eye of the state.

(c) 2000

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