Health Care Mandate Puts a Cranky Uncle in Every Exam Room Money has always played a role in health care, even back in the good old days when Hippocrates charged a drachma or two for a second opinion. Back then it was the coin of the realm that healed the sick, and now, thanks to the upheld individual insurance mandate, it is going to be a little plastic card for all. So nothing has really changed, right? Wrong. Health insurance is more than a cash equivalent. It is cash with strings attached, like a rich uncle with deep pockets but a volatile personality, munificent one minute and stingy the next. This is an uncle who takes you to the doctor but refuses to wait out front with a magazine: He is right there in the exam room with you, commenting on everything. Sometimes he peels the big bills out of his wallet with a smile, and sometimes he scowls, shakes his head and yanks you by the sleeve out the door. Not that your uncle is stupid or misinformed. His opinions can be right on target, and often, if he has misunderstood a situation, he can be persuaded to change his mind. But he never goes away. And so the new mandate will provide millions more people with an uncle. By so doing it will affect not only who gets into the exam room, but also what goes on there - because having an uncle in the room always does influence things, for good or for ill. It certainly does for those of us with the dubious privilege of dealing with many, many different uncles in the course of a workday. Oh, the uncles I have known. Some are sensible but rigid, some are foolish but flexible, and some are just bizarre. Then there is the occasional malevolent uncle who will idly watch you sicken, and whistle as he wanders away. Take the mundane matter of pills. Generally most treatments for common conditions like sinus congestion and acid reflux are equally effective. Insurers, reasonably enough, cover only a few options, often changing their formularies to reflect the best bulk discount available. But frequent sufferers almost always develop a deep attachment to a single product. Your stomach needs Nexium, but suddenly only Prilosec is covered. You snuffle for Flonase, but it's Nasacort for you. You are not necessarily condemned to suffer till the formulary changes back, though, or pay out of pocket for relief. Your doctor's office can fax in a detailed form or make a phone call (either takes about 15 minutes) explaining why you need what you need and, often, uncle will relent. Insomniacs are likely to find their favorite soporific off limits without that phone call. The ads trumpeting the misery of low testosterone may speak directly to you, but quite a few uncles are dubious about that diagnosis. It takes a few phone calls and a couple of forms before your uncle cries uncle and pays. A cardiac patient needed a blood thinner, but could not tolerate the usual one. His insurer reluctantly approved an expensive alternative (after three phone calls and a long written plea). The approval lasted a year. Then the doctor - O.K., it was me - called only to learn that the medication could not be reapproved because it had allegedly never been approved at all. The patient had apparently been swallowing pill-shaped figments of our joint imagination. That particular snarl took a solid hour on the phone to unravel. Another patient needed an unusually high dose of antibiotic for a life-threatening episode of meningitis. His uncle said absolutely not, no way. The doctor (O.K., me again) made five separate phone calls up a hierarchy of insurance pharmacists, faxed the relevant information to each, and no luck. The patient's husband, bless him, then took over the phone work, and the antibiotic was approved the next day, no real harm done. If you are keeping track of outcomes, you note that things often work out fine. But note, as well, the cumulative phone hours involved. And those hours reflect just the problems I could help with. Here are some that left patients on their own: One changed jobs and his new insurance didn't cover most of his medications. So he changed his policy, and suddenly the doctor didn't take his plan. One had an unusual condition; the local specialist took her insurance but the only relevant radiologist in the area didn't. The only plans they both accepted were way out of her financial reach. One had low-premium catastrophic coverage to cover emergencies and hospitalizations. When his cancer was diagnosed, though, it just wasn't catastrophic enough: He remained an outpatient and loaded about $25,000 worth of scans and office visits onto his credit card. One has double coverage - lucky her, that's two uncles - but they are always fighting. You pay. No, YOU pay. Sometimes no one pays but the patient, because she is sick and weak and tired and often just skips office visits, with their inevitable sequelae of confusion, collection agency threats, embarrassment, and her doctor's resigned voice on the phone promising to make a few more calls. Insurance is a good thing. Everyone needs it. Still, let no one underestimate the intrusion, the copious misunderstandings and the incalculable hours medical personnel waste as they address the idiosyncrasies of a dozen different uncles all loudly calling the shots with one eye on the patient and the other on the marketplace. It's enough to make you wish for another option.