My experience with Tricare is it’s like a really strict HMO, and if you don’t follow all their rules, you will be denied coverage. HMO’s aren’t so prevalent now because we refuse to pay outrageous premiums, deductibles and co-payments and have the insurance company tell our doctors what they could and could not do. Doctors had to get permission to practice any kind of medicine, even real emergency medicine in life-threatening situations. That was the start of the health care providers taking care of insurance claims for patients. That started the need for doctors to have to hire so many administrative employees to handle all the new paperwork that was thrust on them that the patients used to have to fill out and file themselves.

I was a Navy brat, born in a Naval hospital. They saved my life and my mom’s, but I hear it wasn’t pleasant. We moved so much that I don’t have medical records from before I was 19, except my shot records. We had to keep those with us at all times. Tri-Care was no fun when we had to go to the doctor on base. It’s fine if you’re outside the 50 mile limit because you can choose your own doctors. Our corpsmen were over-zealous about all immunizations. I ended up with a tetanus shot nearly every year whether I needed it or not, and when they heard their might be sewer leaks in our local neighborhoods, they vaccinated us all for typhoid.

Back when I had to go to TriCare on base, I saw physician’s assistants. Nurse practitioners replaced them, and I’d rather see an NP than PA. I can’t say they ever made me sicker or didn’t help me, but it was typical military life–hurry up and wait. And be ready to talk fast about any previous treatment you’ve had for a specific illness. We didn’t have much choice of meds either, but back then there were a lot fewer meds to give and they weren’t so expensive like they are today. I was beyond needing well baby care, and I don’t remember my parents saying much about problems with well baby care when I was a baby. I was high risk and was seen very often, at least once per month. I only weighed 3 lbs 5 oz when I was born in 1960, a birth weight that usually didn’t survive back then.

My sister was born while my dad was out on reserve duty going to college on the GI Bill before he went back on active duty. My mom had the same OB during her pregnancy with my sister. After that, we had one family doctor who saw all of us, and he was a former Navy surgeon who went into general practice and was an excellent doctor. But that was back in the 60′s when a lot of docs went into the military for their internships and residencies. It paid better, had lower living expenses, and trained surgeons very well since we were in a war at the time (Vietnam).

In the late 70′s, my dad had diverticulitis that required surgery and the only military hospital available in New Orleans at the time was the VA hospital. It was horrible while we were trying to get him properly diagnosed (they didn’t have CT scans or MRI’s so that diagnosis was a difficult one if there wasn’t a blatant rupture). That took 6 weeks before they finally figured out what was wrong and what he needed. Once we had a diagnosis, he got excellent care at the VA. They performed his surgery and he recovered faster and without secondary problems like I had when I had the same thing happen to me. I actually had a rupture with lots of pain, high fever, and was admitted to one of our better private hospitals under employer insurance, Aetna I believe. I had the surgery, got an incision infection and had to heal with the skin open (hideous, huge scar). I got blood clots from being in bed with no anti-embolism stockings or leg circulation pumps. I was on warfarin for 5 months (Coumadin). I also had to have major hernia surgery 13 months after the initial operation. I was lucky not to end up with a temporary colostomy.

I did end up laid off from my job after two major operations and about 6 months total of missed work in a 16 month period at the end of 2003. Everyone who had gotten very sick had been laid off within a couple of years of their illness. They wanted us out of their risk pool. They had to extend COBRA to us for 18 months, but we had to pay for it, and then we were off their insurance. I’ve been uninsured ever since COBRA ran out. My son is on SCHIP, which is a very decent program. It has its problems, but for the most part, it’s a good program.

I’m for a public option that is like Medicare, not Tri-Care. Most everyone on Medicare loves it and wouldn’t cancel it unless it was taken from them. My mom gets Medicare, LA State Group Benefits from her job, and her third insurance is Tricare for Life. With retirees on Medicare they reimburse after all other insurance has paid. She pays nothing out of pocket.

If we end up with a private insurance national exchange that can’t deny us coverage for pre-existing conditions and really has to compete for our business, it might bring prices down quite a bit, although I don’t think it will be as efficient as making a public insurance option available. Still, major reforms of the private health insurance companies, especially breaking their monopolies in many states, will drive costs down. Insuring most people will also spread the risk around better. Even though everyone won’t buy insurance, it should still be required by law like car insurance. If it’s affordable young, healthy people will buy in and lower overall risk which will drive costs down. Focusing on well care, check ups and early diagnosis and treatment, and better management of chronic conditions will definitely save money in the long run.

Even though the GOP is trying to scare the hell out of everyone about it, if more people stepped up and made their end-of-life wishes known and have the proper documents drawn up (ie living wills), it will also save a lot of money. Many people who are at the end of their lives, miserable and in pain and would rather be in hospice with good pain relief and DNR orders so they won’t be given the maximum level of life-saving treatment if they don’t want it. Maximum treatment does cost a lot of money, but it’s not about the money, it’s about what the patient wants to happen at the end of their lives. Many would prefer hospice, and pain and symptom relief care than maximum treatment. But without a living will and an advocate to enforce it, the standard procedure is to provide the maximum live-saving treatments. When I was a nurse’s aid, we resuscitated a lot of very elderly and sick people who didn’t have DNR orders. They would wake up in ICU and ask why the hell we didn’t let them die. Our answer was always the same; they hadn’t signed a do not resuscitate (DNR) order. They didn’t tell us to let them go, so we couldn’t.

I have an infant daughter who is assigned a Primary Care Manager who is supposed to manage her health care. My daughter has already had two different PCMs during her six months on Earth, and has only ever seen one of them. Normally, she has to see a nurse practitioner.

When we try to schedule her well-baby visits, we must call at least three but no more than four weeks in advance, and we still never get to see an actual doctor. We show up for the appointment 15 minutes early as is required (otherwise your appointment will be canceled, even if you are prompt), end up waiting for 45 minutes in a roomful of sick children, then are rushed back into an exam room, where we wait for another 20 minutes or so. The harried nurse comes in, quickly checks her and kicks us out in less than 15 minutes. We then proceed to the immunization room where a none-too-gentle corpsman quickly jams several needles into my daughter’s legs, without the courtesy of telling me which is which so that I can accurately monitor adverse reactions and report them at the next visit. If I complain to the clinic ombudsman about the (mal)treatment my child gets, nothing is done (except that they have an even harder time trying to fit her in for her next appointment!). Given that we never see the same doctor/nurse twice, there is NO continuity of care. Wouldn’t I love for my child to have the same pediatrician for even six months at a time? I feel really blessed to have made it all the way through a pregnancy with the same OB. That’s pretty sad.

If my poor kiddo gets sick from being around a dozen kids with Swine Flu, and I call to make an appointment, I can expect to wait three days before she can see a nurse (where the hell are the doctors, anyway?). If it can’t wait, I can take her to the ER. However, if I take her to the wrong ER, or fail to get Tricare permission within 24 hours of taking her there, I will be stuck paying the whole bill. If I take her to see a pediatrician out in town? Stuck paying the whole bill. I can request a transfer to a civilian care provider but it will be denied as we live within 50 miles of a military treatment facility. If we are vacationing and she runs a fever and needs to see a doctor, I have to take her to an ER and get permission within 24 hours, or they won’t pay for it.

For prescription drugs, a very narrow range of formulations and pills are covered. If you have GERD, you get esomeprazole. Insomniacs get Ambien. Ortho-tri-cyclen is your triphasic birth control. In very rare instances when people have life-threatening allergies will an exception be made, but it has to be fulfilled by an outside pharmacy where a copay applies, and it is not transferable from duty station to duty station. The little upshot is that multivitamins and motrin are free.

Your medical records are property of the US government, and if you want a copy of them, submit a request and prepare to wait at least 30 business days. You may not photocopy your own records. Your records are often irretrievably lost when you move. Basically, memorize your blood type, your allergies, and any other information that may be helpful to any future doctor who will treat you. Prepare to have unnecessary and redundant labs performed when the doctor doesn’t believe that you are O- and do in fact need Rhogam after delivering an Rh+ baby. Expect an extra flu shot, and be willing to fight for your tetanus booster!

As tedious as this is, it’s a far sight better than the VA. The VA simply doesn’t provide care at all.