Insurance and inoculations
Logic isn’t always logical
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As a person ‘of a certain age’, I shook my head reading a headline this morning ‘Some Older adults Are Being Charged Over $300 for the New R.S.V. Vaccine’, with Dana Smith providing the byline. Like so many things about our insurance system, it appears utterly irrational.
R.S.V., or respiratory syncytial virus, aflicked hundreds of thousands across the country last year, particularly hitting children and older adults. It afflicted someone close to me and it was nasty and quite scary in its depth of debilitating effects. The urgent care doctors did not even test for it when the patient checked in with severe symptoms on a Saturday morning.
As a result, my husband and I eagerly went to the nearby drugstore over a month ago when we heard the Federal Drug Administration approved new vaccine to combat this condition.
The first bizarre thing (which should not have surprised us but did) was that Maryland had yet to authorize its use in state. We are certainly aware of local law enforcement, local school districts, local taxes but had not considered that the state officials would not accept the federal government’s approval as authoritative for immunizations. Federalism is a weird process when you really think of it. We most definitely have state, and occasionally local, laws that do not sync with federal decisions. We both assumed that would gain approval rapidly as we got closer to the prime R.S.V. Season beginning this autumn but not yet.
Then this newspaper story pointed out the challenges and financial costs of receiving the injection because of different providing authorities. If you’re not ‘of that certain age’ yet, you have a delightful choice ahead with Medicare. When you go into the system, a federal health care system, you will decide to pay for drugs and shots under what is known as Medicate Part D, or you choose to use some private insurance company. You will pay for one or the other so it’s not as if this decision entitles you to completely free medication and inoculations; the choice is simply which authorities you will be under.
I had a good health care plan for my working years so I chose to stick with private insurance rather than the Part D coverage. I should add that Medicare basic care is what you must enroll in at ‘tha certain age’ which you also pay for. While these are often called entitlements, it’s not quite that simple. Medicare—which you pay for under a means testing calculation— covers certain basic costs and fees, requiring you to find a doctor who will accept that payment level if you are unable, as millions cannot, to supplement the payment with private health care. In short, it is tres complicated.
But the issue today is the drug coverage. The crux of the issue is that Medicare Part D, something those of us at ‘that age’ are familiar with, pays for this new immunization while private coverage is hit or miss. In the case of this new vaccination, some insurance companies are covering it while others are charging an out-of-pocket cost upwards of $300 per inoculation. The story cited a fellow having to pay $330 for his shot.
Some people find $330 a rounding error in their incomes while it’s a substantial chunk of change for someone’s budget who did not prepare for it. Yet I can say authoritatively that R.S.V. Is a terrifying illness for someone older and it apparently circulates rather easily so one might be best to get the injection as soon as possible. But, how?
The article did note that the insurance companies argue it’s not nearly as important as I am arguing here because R.S.V. does not yet appear the F.D.A.’s regimen of annual shots for adults. Yet, the same agency’s Advisory Committee on Immunization Practices advises the administer of the shot following consultation between a physician and patient over 60 years old. What does that mean?
It is madness. Either it’s important enough to authorise its fee-less administer by all as we did with COVID or it isn’t. Yes, I can probably afford $330 if my insurance won’t cover it (since I cannot receive the immunization in Maryland yet, I don’t know) but is the profit motive more important or public health with the evidence of the transmissibility of R.S.V?
I am well aware that few lightning rod issues exist in America to the same degree as access to health care. I know at least a couple of people who read this are in Britain when health care problems in 2023 show the danger of a medical system under incredible strain. But health care in this country shows the reality that it’s not a choice of whether you’ll get something but when you’ll get it and how much you’ll pay. If someone becomes immobilized with R.S.V., I guarantee hospitalisation will be more expensive and keep a bed unavailable to someone else.
In the end, I suspect the FDA will put R.S.V. On its recommended list so private insurance will pay for older citizens to receive it. I am not suggesting that every injection should become a health care emergency but I am mesmerized by the unpredictability of a health care system with an aging population as diseases seem to proliferate. And then there are the kids….
Actions create consequences in health care, government, and life among other things. It’s miraculous we have such quick responses to emergent medical threats which I do not take for granted. But, I also have a hard time tracking the logic much of the time.
Be healthy and safe. FIN.
Center for Disease Control, ‘Adult Immunization Schedule, 2023,’ retrieved on 27 August 2023 at https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html
Dana G. Smith, “Some Older Adults Are Being Charged Over $300 for the New R.S. V. Vaccine’, NewYorkTimes.com, 25 August 2023, retrieved at https://www.nytimes.com/2023/08/25/well/live/rsv-vaccines-health-insurance-medicare.html