The American Healthcare Insurance Disaster: Observations and Evidence from ACL Surgery

American medicine is dominated by insurance companies who insist on treating patient health as a business instead of focusing on fixing patient’s problems. Doctors, Physical Therapists, and other health care workers are at the mercy and whims of insurance companies in terms of their ability to proceed with patient care. Let me explain from my experience.                                  

It was 8 pm, and I was only halfway done with the first step of my experiment. I was going to the gym to take a mental break from my building frustration. I had forgotten my water bottle, so I was rushing through the parking lot when it happened. One wrong step, and I collapsed on the ground, my knee crunching on the way down. Immediately, I look around for people who may have seen me embarrassingly trip over nothing in a flat parking lot. The coast was clear, so I go to stand and walk to my car, but I discovered I couldn’t. 

Of course, I couldn’t; I had torn my Anterior Cruciate Ligament, commonly known as the ALC. Actually, that’s a bit of an understatement. I destroyed it, ripped it fully in half and (because apparently that wasn’t theatrical enough for falling in the parking lot). And with one wrong step, I began a months-long battle for recovery. 

I’ll preface the rest of my story with this caveat: My dad is a doctor and has many connections in my hometown medical community and I was taken care of, for the first month at least, in my hometown. Because of my dad’s connections, I was able to get into see an orthopedic surgeon the next day; most people have to wait weeks for that appointment. 

At my doctor’s office I explained what happened and they took x-rays. When everything appeared normal, my doctor ordered an MRI and prepared me for the worst, which meant ACL repair surgery.

 I was lucky enough to get an appointment for an MRI the same day, with the stipulation that my insurance approved said MRI scan. I took the day’s last MRI appointment, andmy insurance waited until the last minute to approve it. 

The MRI showed the worst, so I scheduled surgery for the next week, which is likely because of my dad’s friendship with my doctor. 

The day before my surgery arrived, the surgery center called me to tell me that my insurance has not yet approved the surgery. After several calls from the surgery center, my doctor, and my dad, we finally found out that my insurance company didn’t want to approve the surgery because they saw it as “elective” or nonessential. According to my insurance, a surgery that would literally restore my ability to walk is optional, and they were telling me no. 

I had to reschedule my surgery to fight the insurance company. Luckily, we pushed back and got the surgery approved. But for some people, a similar surgery being rejected by insurance means that they just wouldn’t be able to get the surgery. In 2016, almost 20% of Americans skipped medical procedures, tests, treatments, and/or follow-ups because of cost.

After my surgery, my doctor sent orders for me to go to physical therapy 3 times a week for 24 weeks (about 6 months). That would be 72 visits. However, my insurance will only allow me to go to physical therapy 20 times in a year or a little more than 25% of what I’m supposed to get.  That’s not even enough to go once per week for 24 weeks. My insurance essentially vetoed 4 months of my recovery. 

While I am still meeting major milestones, my doctor and physical therapist have told me that my recovery has been severely limited by my insurance refusing to allow me more visits. I am going to have to start paying out of pocket for my visits to physical therapy because I am still recovering and need to go. But unfortunately, I’ll have to stop in September because I can’t afford to keep paying out of pocket.I’ll just have to hope that I can continue recovering on my own based on advice given to me by my physical therapist. 

Why is my insurance dictating my recovery? I have a decent health insurance plan, and I’m still getting shafted. My health shouldn’t be treated like a statistic for a business. Patients aren’t numbers you can play with; insurance companies are essentially playing God when it comes to people’s health and overall quality of life. You’d think that they’d want to give people the chance to be their healthiest, so they don’t have to pay for that same person to go back to the hospital. 

And before you dismiss me as an entitled college student spewing utter nonsense, you should know that I’m not alone in my dismal opinion of our current healthcare climate in America. A 2013 survey done in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States revealed that American adults were significantly more likely to skip essential medical treatment because of cost, struggle to pay for medical care even when insured, and run into unnecessary red tape due to insurance complexity. American adults had longer wait times and opted to use an Emergency Room more often for minor illness (the flu for example).  75% of American adults think the healthcare system needs a complete overhaul. Additionally, another study done in the United States, Canada, and Germany found that 60% of American adults thought that the system needs rebuilding and only 10% thought that the system could be improved with minor fixes. 

Keep in mind, our current system doesn’t benefit medical professionals either. The reason you spend so little time with your doctor during a check-up these days is because of insurance companies. Insurance companies are forcing doctors to spend time on busy work, instead of treating patients, or face fines in the name of “quality assurance”. 

One study showed that doctors in family practice, general internal medicine, cardiology, and orthopedics spent over $15 billion in 2015 doing insurance busy work, which amounted to an average cost of $40,069 in medical professional time per physician per year. Worst of all, the quality assurance doesn’t look at patient recovery but instead looks more into what kind of medicine doctors are using for treatment and how often they use it. These practices do little to benefit the patient and only increase the likelihood of physician burnout. 

There are many options for improving our current system. This could be done by expanding Medicare and turning to a single-payer system, direct primary care coupled with current private insurance plans, or even paying out of pocket for nonurgent illness and leaving insurance to cover more complex modes of care (surgery, hospitalization, MRI). No matter how we do it, we need to restructure our system to better serve patients and medical professionals, not insurance companies.