Insurance Status Determines Care

When I was diagnosed with chronic myelogenous leukemia, I crossed into dangerous territory that the insurance companies call “liability.” Although the science may exist that could give us back our health, the insurance companies may not pay for it and the cost to individuals is prohibitive.

The labyrinth of issues created by drug companies, the government (Medicare) and private insurance companies that physicians and their patients must navigate is complicated at every turn. Sometimes there really is no way out. It is especially maddening in a country where the best available health care should be a right.

You and your physician know what ails you and how to fix it. But your insurance company has to agree to pay for it. Either that or you decide that you can pay the bills.

For those of us with private insurance the danger is having our premiums raised when the bills get too high or having the insurance canceled. For those on Medicare, the situation is a lot worse.

Your life has just been reduced to the cost of premiums divided by the cost of your treatment and multiplied by whatever factor the insurance company uses for its profit margin so it can stay in business for everyone else. It’s a mean equation.

But let’s not make this a blame game. For the sake of discussion, let’s say that the insurance companies are right. They really cannot afford to cover the expensive drugs and procedures that our pharmaceutical companies and equipment manufacturers are providing.

The question then becomes one of priorities and who has the right to set them. Pharmaceutical companies produce drugs based not only on societal need but on whether that need can be translated into enough sales to turn a profit to pay for the next best thing coming through the pipeline.

Science and technology are evolving at such an accelerated pace that the structure for getting their miracles to patients who need them is outdated. We seem to have gotten ahead of ourselves.

I take Gleevec, a new cancer drug that molecularly targets the protein that feeds cancer cells, thereby killing them and with few side effects. Approved by the FDA last May, it is viewed as a drug that can manage this disease for most people and may cure some patients. My insurance covers this prescription and the co-payment is only $10. The cost is $4,800 per month. Were I on Medicare or my insurance did not cover it, I could not afford Gleevec. Not taking it could easily cost my life.

Two measures pending in Congress would expand Medicare coverage to all oral cancer medications. There will be more molecularly targeted drugs that could be lifesavers for people with various types of cancer.

Are pharmaceutical priorities skewed to profits more than to patient needs? How about the politics of Medicare? Who benefits when older patients do not get the care they need and deserve but cannot afford? It is frightening to think that a 56-year-old woman with private insurance can have Gleevec but a 65-year-old retired woman with a fixed income who is on Medicare cannot.

We are real people with real ailments that have real, available remedies. There should be a way to get them from that brilliant team of researchers in the lab to us at the drugstore counter without breaking anyone’s bank.