Sure we have all heard about the uninsured, the 46+ million and growing... but hey "I have insurance" you say, "so I am okay."
Or maybe not!
The American Cancer Society has been collecting stories of people with cancer unable to afford care even with insurance, and they testified to Congress this week:
Much of the public debate today is about the need to cover the 47 million uninsured, and the American Cancer Society fully shares that concern. However, we need to recognize more fully the very significant problem of underinsurance. Health plans vary enormously in their deductibles, co-pays, benefits covered, and exceptions. Insurance plans are written in very detailed legalistic language that very few lay people can begin to comprehend, and the summary plan documents that are provided to enrollees almost never begin to convey the adequacy of coverage.
Below are stories from Tom, Doreen, Randy & others...
Put another way, if you were to look at an array of plans that might be available to you as a consumer, and you were to ask, what would be the adequacy of your coverage if you were to be diagnosed with cancer or some other serious disease, you would probably conclude that you have no idea whether the plan would be adequate.
Here are some more people from the ACS testimony:
Doreen's story:
Doreen, a 57 year-old former medical office receptionist, was diagnosed with Stage IV breast cancer in the fall of 2005. The cancer metastasized to her spinal column, liver, lungs, and left femur. Doreen and her husband, a retired New York City police officer, have health insurance through his retirement plan. The insurance covers 30 outpatient visits a year, a number Doreen quickly exceeded after beginning treatment for her cancer. After she reached this annual limit, she was billed $5,000 a week for chemotherapy treatments. In less than a year, Doreen and her husband owed more than $100,000 to the hospital for her treatment. By the time Doreen's insurance company informed her that she had exceeded her maximum number of outpatient visits, she had already made additional visits the plan would not cover. Fortunately for Doreen, she spoke at an American Cancer Society event about her inadequate insurance and the story ran in the Long Island Newsday. Upon reading the article, the insurer reversed the decision and paid Doreen’s medical bills in full. While Doreen’s story turned out well, countless others are not as fortunate to have a platform to share their story.
Martha:
Martha, a 63 year-old retired woman, was diagnosed with Stage I breast cancer in November 2007. For her cancer treatment, Martha had surgery followed by radiation. Martha is now post-treatment, but still needs periodic follow-up visits to her oncologist to monitor for recurrence. Martha has a health insurance policy, but the policy is inadequate for her needs. For example, the insurance paid $1,000 of a $10,000 hospital bill for her surgery. Martha said she is $28,000 in medical debt due to her cancer diagnosis, and the hospital is threatening her with a collection agency. Martha lives in a state that has a medically underwritten individual insurance market, so it is unlikely she would be offered another policy. Martha beat her cancer, but now she is struggling with keeping her head above water financially.
Not just women and breast cancer...
Thomas:
Thomas, a 35 year-old married father of three, was diagnosed with testicular cancer in March 2004. At the time, he was insured able to get the appropriate care to successfully treat his cancer with surgery and radiation. Thomas’ wife called HIAS because Thomas was without insurance and needed follow-up care to ensure his cancer remained in remission. Thomas could not receive the follow-up tests, which cost more than $2,500, without insurance or a means to pay. Since his remission, Thomas started his own business and lost his previous coverage. He attempted to get coverage in the individual market, but due to medically underwriting he was denied several insurance policies. Thomas was eligible for the state high risk pool; however, Thomas said the 12 month pre-existing exclusion period renders this option not viable. Thomas remains uninsured and unable to access the follow-up care to monitor his health.
What does "having health insurance" really mean? You have to ask yourself the following questions:
- How expensive is the premium, or whatever part of buying or sharing the cost of coverage that you have to pay?
- How high is the deductible, the amount of the bills that you have to pay all of, before the insurance begins to pay?
- Is it one deductible per year, or is it a separate deductible for each condition (don't have two or more different sicknesses or diseases).
- Even after the deductible, does the plan pay 100% of costs or only some percentage of the bill (perhaps 80%; leaving you with 20% forever).
- Is there a maximum that the insurance will cover up to (a cap), after which you are on your own again?
- Is there an annual cap? Is there a lifetime cap?
- Does your insurance cover prescriptions (at least 10% of private insurance does not at all)?
- Does your insurance cover dental care (29% of private insurance does not at all)?
- Does your insurance cover eye care (37% of private insurance does not at all)?
- Do you have insurance all the time, all year, every year, or are you sometimes insured and sometimes uninsured?
- What percentage of claims that are filed, does the insurance company initially reject or refuse to pay in full? How much paperwork and hassle do you have to go through to get them to cover what you are owed. And were you still screwed in the end, compared with what they initially assured would be covered?
If, despite officially "having insurance" you still, literally cannot afford to be sick then you are underinsured.
Randy, 63 years old, Pennsylvania
Following his diagnosis with Stage IV esophageal cancer, Randy had surgery to remove his esophagus and stomach. Radiation and intense chemotherapy followed. Randy quickly reached the $100,000 lifetime cap on his major medical coverage and now receives no further benefits. He has paid out of pocket for follow-up scans and labs to monitor his condition. Because he had 18 months of continuous, creditable coverage, Randy would’ve been eligible by federal law for a policy with no pre-exclusionary period. However, he wasn’t aware of the option until after it had expired. Meanwhile, Randy and his wife are ineligible for AdultBasic or Medicaid, and he is unlikely to get private insurance due to medical underwriting. Randy’s only option, a guaranteed issue policy, includes a pre-existing condition exclusionary period of up to three years. The policy allows for riders that could modify the benefits and conditions of his coverage. Ultimately, Randy will have to wait two years to become Medicare eligible. He has no other choice.
Valerie, 34 years old, Georgia
Valerie, a mother and wife, is a contract worker for a small staffing agency. Her husband, Jeff, is a car salesman. The family’s income fluctuates based on her workload and his commission. Valerie was recently diagnosed with Stage IV breast cancer and is currently undergoing treatment. She has employee-sponsored insurance through the staffing agency, but she quickly met the plan’s $10,000 yearly maximum benefit. She now owes $6,000 in bills to her oncologist’s office and is responsible for the cost of her treatments moving forward. Those treatments include three more rounds of chemotherapy and potentially radiation or surgery. Valerie doesn’t want to change insurance, largely because the other members of her family are covered under her plan. Jeff doesn’t have access to employee-sponsored insurance at his job. Valerie will likely be denied insurance in the individual market because of medical underwriting. Therefore, she can’t buy a supplemental policy to cover her chemotherapy. She will continue paying her considerable treatment costs out of pocket.
Survey data from the Kaiser Foundation (.PDF) in 2002 showed that among persons who were insured:
- 24% of insured families spent $2,000 or more out-of-pocket expenses on health care.
- 18% reported postponing seeking care due to costs
- 15% had problems paying medical bills
- 10% had needed a prescription filled, but did not get it
- 8% were contacted by a collection agency about medical bills
- 6% needed medical care but did not get it.
Depending on the exact definition used, somewhere between 12% to 18% of Americans ages 19-64 are UNDERinsured.
And that was before the expansion of Tier 4 drugs, the highest cost drugs with super high co-pays.
Kay, 61 years old, Florida
Kay works part time at a large department store earning $13,000 per year. She has insurance through her employer but quickly exceeded the plan’s $25,000 annual maximum following her diagnosis with Stage II breast cancer. She has received eight cycles of pre-operative chemotherapy, had a lumpectomy with auxiliary lymph node dissection, and now needs radiation. Kay already has $40,000 in outstanding medical bills from various diagnostic tests that were not covered. Now she’s been told that she cannot begin radiation unless she plans to bring $115,000 with her to the first appointment. Kay’s Medicaid application is pending; it will take months before she learns if help is available. Meanwhile, she will likely be denied private insurance because of medical underwriting. Kay has no adequate insurance options.
Bettie, 57 years old, Florida
Bettie works at a toll both in Florida. She exceeded the $50,000 annual maximum on her employer-sponsored insurance within six weeks of her breast cancer diagnosis. Bettie had a lumpectomy followed by auxiliary dissection of her underarm lymph nodes. She has been unable to start radiation treatments and is now uninsured; her plan was terminated when her employer changed parent companies. Bettie has been told that she cannot enroll in the new employee-sponsored plan until she returns from short-term disability. She is currently caring for her husband, a double amputee, and spending many hours searching for a way to afford her radiation treatments.
Another study in 2005 by researchers for the Commonwealth Fund, used the following definition for adults 19-64 years old (that is people too old for Medicaid and too young for Medicare):
You were UNDERinsured, if you did have insurance for the entire year, but also had any of:
- Annual out of pocket expenses amount to 10% or more of income; or
- If your incomes was under 200% of poverty level (low income) and out of pocket amount to 5% or more of income;
- Health plan deductibles were 5% or more income.
Using that definition, they found that:
- 12% of adults who had insurance all year, met the criteria for underinsured.
- The number was much higher, 73%, for adults with incomes under 200% of the poverty level and had insurance were still underinsured.
- Perhaps most frighteningly, among persons with chronic disease or reporting poor or fair health, 43% (more than 3 times the average) were underinsured by this definition.
- 37% of adults were having difficulty paying medical bills or had accrued medical debt.
Comparing those with no insurance to those who were Insured and Underinsured, they found that people reporting that they:
- Went without needed care due to costs (did not fill prescription; did not see specialist when referred; skipped recommended medical test, treatment or follow-up):
a. Insured = 25%
b. Underinsured = 54%
c. Uninsured = 59%
- Contacted by a collection agency about medical bills:
a. Insured = 11%
b. Underinsured = 46%
c. Uninsured = 44%
- Changed way of life to pay medical bills:
a. Insured = 7%
b. Underinsured = 35%
c. Uninsured = 28%
In other words, being underinsured makes you a lot like being uninsured.
Andrew, 19 years old, Rhode Island
Andrew was recently diagnosed with Hodgkin lymphoma. He is on leave from his landscaping job and receives $641 per month in unemployment compensation. Andrew’s outstanding medical bills currently total between $15,000 and $20,000. He has private insurance but his treatments sometimes exceed the policy’s limit of $1,000 per day for chemotherapy. The insurance also does not cover many of his hospital costs. Andrew’s boss has offered him a different insurance policy once he returns to work. Andrew will elect the new coverage option when the time comes. However, his medical debt will remain.
Donna, 45 years old, Ohio
Donna has two children. She works full time, and her annual income is $27,000. She was recently diagnosed with breast cancer. Donna does have health insurance, a major medical individual policy that she purchased after her company ended its group plan. However, she quickly met the $10,000 limit on outpatient services under her new plan. Donna’s treatment, including 15 chemotherapy sessions, has left her with more than $100,000 in outstanding medical bills. Donna is uncertain how she is going to pay the debt and handle future out-of-pocket costs. She had been supplementing her income through a second, part-time job but had to give that up once her chemotherapy began. Donna’s hoping she can get one of Ohio’s guaranteed issue policies, which are limited by enrollment caps. The plans are only available during an annual 30-day open enrollment period, so Donna will wait to see what happens. She has no insurance options otherwise.
Medical Bankruptcy:
The 2005 study out of Harvard showed that:
- Half of all bankruptcies in the United States are due to medical expenses
- From 1980 to 2001 the annual number of bankruptcies tripled overall, while those due to medical expense went up 23 fold.
- 76% of people who had a medical-related bankruptcy had health insurance when they first became ill.
- 38% of those who filed for bankruptcy lost their health coverage at least temporarily by the time they had declared bankruptcy
- Most of those who filed for bankruptcy because of medical costs were middle-income homeowners, the study indicates
- For people filing bankruptcy, out-of-pocket medical costs averaged $13,460 for those who had health insurance, compared with an average of $10,893 for the uninsured.
- The highest costs — $18,005 on average — were incurred by people who had private health coverage at the beginning of their illness but later lost it, according to the study.
- For patients with cancer, average out-of-pocket costs were $35,878.
- Employer-sponsored health insurance does not shield families from high medical costs because an illness can lead to job loss and loss of health coverage.
- People who cited medical bills as a cause for filing bankruptcy were more likely than others to have experienced a gap in health coverage because of costs or because they switched to a new plan and then lost coverage because of pre-existing medical conditions.
- 33% of those who filed for bankruptcy because of medical costs said they still have difficulty paying bills, such as mortgages, utilities and rent.
As this week's story from the NY Times about soaring co-payments drives home, even if you have "insurance" once you actually get sick and need it, you are still likely to be screwed with unafordable out of pocket expenses, bankruptcy for your family and death for you (not kidding; people with insurance not getting their cancer drugs!).
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Some Political Implications:
- Underinsured is an underemphasized part of the health insurance crisis in America
- Emphasizing the underinsured bolsters people's understanding of the real problem, and promotes support for true universal health insurance by pointing out how vulnerable we all are, even those who "have insurance."
- Most current health care proposals, including McCain, Clinton, Obama and Wyden's do nothing for the underinsured, because they continue to rely on the private sector plans that deliberately provide such incomplete coverage.
- By going the single payer route, and cutting out the unnecessary private for-profit insurance industry that only competes in how they can not provide coverage (what they call medical loss; what we call coverage for care) we fully cover not onlyh the uninsured but also the UNDERinsured.
- Regardless of the Presidential campaign and proposals, it is important to have a strong better option coming out of Congress.
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John Conyers is the lead sponser for HR-676, "Improved and Expanded Medicare for All", would institute a single payer health care system in the U.S. by expanding a greatly improved Medicare system to every resident: It would cover every person in the U. S. for all necessary medical care including prescription drugs, hospital, surgical, outpatient services, primary and preventive care, emergency services, dental, mental health, home health, physical therapy, rehabilitation (including for substance abuse), vision care, hearing aids, chiropractic and long term care. HR 676 ends deductibles and co-payments. HR 676 would save billions annually by eliminating the high overhead and profits of the private health insurance industry and HMOs.
The bill garnered 88 co-sponsors so far, more than any other reform proposal, including the chairman of Ways and Means (Rangel, D-NY).
So, here is what YOU can DO now:
- Ask your congressperson to sign-up as a co-sponsor of HR-676! You can look-up your elected officials here
- Get any organization you belong to -- civic, religious, labor, community, etc. to pass an HR-676 endorsement resolution: Here is how to do that via Physicians for a National Health Program. Or here if you prefer via a non-physician group.