Good governance, bad governance, and health insurance

I have spent the morning puzzling over my health insurance options for the upcoming year, comparing various plans offered by my new university. Choice is good, right?

Choice is good, except when you're trying to simultaneously compare the labyrinthine language of three different health insurance plans. There's no doubt in my mind that such confusion is intentional on the part of the insurance companies; who wouldn't rather just sign on the dotted line and be done with it? That's what the companies hope for: that we'll assume they are taking care of us, and waive our rights away.

Not this time.

I've gone in and out of enough insurance plans over the last four years to be somewhat wary of starting over again with a new plan. In my case, I have been very fortunate: I have never been hospitalized; my health is good, overall; no serious medical conditions to look after, etc. My only real health concern, this time around, has to do with starting psychotherapy again, this time without meeting DSM-IV criteria for an eating disorder, and I'm hoping that I can get at least some coverage from my health insurance to do so.

The reasons that I want to start psychotherapy have little to do with what brought me into treatment seven years ago for an eating disorder, and are more like the everyday things that bring most folks into psychotherapy: life stresses, career changes, family problems, etc. These, and the fact that I'm starting a Ph.D. program in clinical psychology, and would relish the chance to be in therapy again myself before I start to see patients. So in this situation, I ask myself, is it even ethical for me to seek coverage for psychotherapy for the condition of "eating disorder"? Conversely, might I consider these life stresses as possibly related to the eating disorder I once had -- as risk factors for a possible relapse -- and thus justify my treatment?

Regardless of whether it is ethical or not, I am left with a lot of uncertainty about whether I'll even qualify for coverage under the best of these plans. On the one hand, it offers coverage equivalent to other medical illnesses for "biologically-based mental illness," including "anorexia and bulimia". It is wonderful that this plan offers parity for mental health care, especially given the attention that the issue has received in the news recently. But I wonder how far such parity will go: if I am presently asymptomatic, does that mean I can't receive coverage? Or does my one-time diagnosis of an eating disorder last a lifetime, if it were? (Once a bulimic, always a bulimic?) Additionally, as this is a "pre-existing condition," though one not treated in the last six months (as they define pre-existing), will I be excluded from coverage for another 12-months (as the plans threatens)?

I can hardly get my mind around whether or not I'm eligible for treatment, so I can only anticipate the problems that will ensue once I actually sign up for the plan and attempt to get the coverage that I feel is due. It is dishearteningly for me, both as a patient and as a future mental health professional, to see all of the obstacles that are put in patients' way as they try to get treatment. I am reminded of Franz Kafka, of Jorge Luis Borges, of Ambrogio Lorenzetti's frescoes of Good and Bad Governance that we saw in Siena this summer.

One side of Lorenzetti's fresco (the first image of the post) depicts the effects of good governance: the exercise of justice; profitable businesses; happy and healthy citizens. The other side of the fresco (detailed to the right) shows the effects of bad governance: persons unjustly imprisoned; crop failures; violence; poverty; plagues and pestilence. These murals were intended to teach the rulers of Siena the importance of good governance for the health of town and country.

If the state of our health care system in the United States is any indication, I would say that we are erring on the side of bad governance. If not, why do we put the burden on the ill to know their rights and insist on receiving their benefits? Why is it left up to me to try to understand whether or not I should be covered for psychotherapy? Why do we seem to be hurtling ourselves head-first into the scene depicted below, a desolate countryside full of starving and sick individuals? I am concerned for myself, but I also recognize that mine is not a severe case; whether or not I get coverage, whether or not I'll get treatment, I'll basically be all right. But what of the thousands of people who won't be all right? Who have never been "all right"?

I can only hope that these strangers, other Americans with mental or physical illnesses, can find some clause in their insurance allowing them treatment; that they have family members willing to make phone calls when they are too sick to care; that they have considerate doctors who choose appropriate, economical, humane forms of treatment; and that we see some shift towards "good governance" with the elections in the fall.

I'm voting for better healthcare. And you?

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