HELENA – Thirty-year-old Melissa Armington of Billings has shopped around for health insurance, but no one wants to cover her: She was diagnosed with multiple sclerosis last year.
“I’m supposed to see a neurologist every few months because of my condition, but I put off a lot of the visits, because it’s $300,” she says. “I just can’t afford it all the time. When you can’t afford it, you just don’t go.”
Armington and thousands like her are supposed to be helped by health reform bills before Congress. But what form will that help take? Will it actually work, and how?
To attempt to answer these questions, the Missoulian State Bureau today looks at five individual Montanans, their health care insurance dilemma, and how it might change under the major reform bill sponsored by Montana’s Sen. Max Baucus.
State Bureau reporter Mike Dennison also talks about how the bill affects people who already have good employer-sponsored health coverage, by looking at his own family’s situation, which has an unusual twist. (See Dennison’s column on page B1.)
Baucus’ bill no doubt will be amended as Congress acts on health-reform measures in the coming weeks. But it’s considered a likely template for the final version of any reform bill.
For some Montanans either without health insurance or with costly insurance, the bill offers generous government subsidies to buy decent policies that aren’t widely available on the current individual market. Others simply may be covered by an expansion of government programs, like Medicaid.
The catch, however, is that these changes don’t happen until 2013. There’s also no way to know precisely much these private insurance policies will cost by then, or what they will cover.
The bill does include a “high-risk pool” that will offer coverage almost immediately for people who’ve been denied coverage because of pre-existing health conditions, such as Armington’s. But details of how this plan would work, what it would cost, or what it could cover also are unknown at this point – although Senate staffers say it’s supposed to be good, affordable coverage.
Ty Matsdorf, a spokesman for Baucus, said that while some of the effects of the bill will take time, “this legislation will serve as a cornerstone to build upon for generations.”
“Max knows that the status quo for health care in Montana is unacceptable and unsustainable,” he said. “The bottom line is we can’t do nothing; we must pass comprehensive legislation.”
Some of those interviewed by the State Bureau were discouraged by the wait for change and the uncertainty of what assistance may be there. Others said they’ll take what help they can get, and be happy to see it.
“It gives me a little bit of hope that some day I’ll be able to afford my medication and I won’t have to struggle so bad to see a doctor,” Armington says.
Insurer won’t cover treatment from only doctor who has helped
Beth Ferris, 59, Missoula
Beth Ferris, a self-employed writer and filmmaker who suffers from chronic fatigue syndrome, has had to buy health insurance since 2000 from an insurer-of-last-resort program known as the Montana Comprehensive Health Association – but it’s not what she considers good coverage.
It’s expensive, the deductible is high and it has repeatedly refused to cover treatment from the only physician she says has helped her improve physically.
“They have made a point of turning me down,” she said. “They won’t pay for a doctor they say is experimental, when all along he has turned out to be correct.”
Ferris paid $5,600 this year in premiums for her current policy that has a $7,500 deductible. Last year, she had more than $15,000 in medical expenses, and her insurance covered virtually none of it.
She’s been able to get by on some investment income and help from others, but this year considered selling her house and dropping her health insurance. She finally decided to rent out half her residence in Missoula.
Under the health reform plan before the U.S. Senate, sponsored by Sen. Max Baucus, D-Mont., Ferris could be eligible to get coverage next year from a new, national “high-risk” pool for people with pre-existing health conditions.
However, it’s not clear that she would be eligible – and even if she is, it’s not yet known how much the coverage would cost or what it would cover.
Otherwise, she’d have to wait until 2013 for any new chance to buy affordable insurance, with the help of government subsidies.
The bill would prohibit health insurers from rejecting Ferris or charging her more because of her illness.
The question then becomes, how much would this coverage cost?
The Kaiser Family Foundation, a nonprofit group closely examining the reform bills, estimates a policy for Ferris would cost about $8,000 a year now, and that she’d be eligible for a subsidy of $5,000 under the Baucus bill. She’d pay only about $3,000 herself.
Kaiser based its calculation on a policy that would require patients to pay about 30 percent of their medical costs, likely with a deductible in the $2,000 to $3,000 range, with some limit on out-of-pocket expenses.
Ferris said this type of policy would be a vast improvement – but only if it covers her doctor in North Carolina, which it may not. Also, she’d have to wait nearly four years for it to happen.
“I think (the reforms) are valuable to some people,” she said. “If it truly covers those who have no insurance and can’t afford it, that’s great.”
But for those who are sick, without insurance or with poor insurance, and who are paying huge medical costs, waiting four years is a hard pill to swallow, she said.
“I was really excited by health care reform initially. … My excitement has diminished. I have to wait to see what actually happens to people who do fall through the cracks.”
‘Pre-existing condition’ hell for Billings family
Melissa Armington, 30, Billings
Melissa Armington and her husband, Bob, who have five children, have no health insurance for themselves. Their children are covered by the government-funded Children’s Health Insurance Plan, but her husband’s current employer doesn’t offer health insurance for him or the family.
Last year, Armington was diagnosed with multiple sclerosis after she went blind in one eye. She says she’s tried to find health coverage, but insurers routinely turn her down because of her “pre-existing condition.”
Under Baucus’ reform bill, Armington likely would be eligible for a high-risk pool created next year. It’s not known how much the coverage might cost her, or what it would cover – although Baucus staffers say the insurance pool is supposed to be affordable for people.
Almost certain, however, is that the bill eventually makes Armington and her entire family eligible for coverage under Medicaid, the state-federal plan that covers medical costs for low-income households. The Baucus bill expands Medicaid to cover everyone earning up to
133 percent of the federal poverty level, or $44,000 for Armington’s family of seven.
However, that expansion doesn’t occur until 2013, or four years from now.
Also, starting in 2013, Armington could shop for private insurance and possibly get government subsidies to help her pay for it.
Insurers couldn’t turn her down or charge her more money because of her medical condition as of 2013. The Kaiser Family Foundation estimates her policy would cost $2,700 a year now. The amount of subsidy would depend on how much income is attributed to her.
Armington said the hope of getting insurance at an affordable price, even four years from now, is worth something.
“At least (insurers) won’t be able to tell me it’s not worth it,” she said. “The way they make you feel now, it’s like I’m not even worth trying for. I hate that. I have multiple sclerosis, but I’m still walking and talking. I think I deserve (care) just as much as anyone else. It’s not like I planned on getting sick.”
Employed, but uncovered at 35 hours a week
Eric Dunn, 29, Great Falls
Eric Dunn is campus supervisor at Paris Gibson Education Center, an alternative high school run by the Great Falls School District. He earns just over $10 an hour, but can’t get health insurance through the school district because he doesn’t work full time (he works 35 hours a week).
His parents pay for his health coverage, an individual policy with a $5,000 deductible, that costs about $2,200 a year.
His mother, Kathy Dunn, said the price of the policy has doubled in the past five years, though her son has had no injuries and rarely, if ever, goes to the doctor.
Dunn said if his parents didn’t help him out, he wouldn’t have health insurance, because it would cost at least 15 percent of his take-home income.
Under the Baucus bill, Dunn would be required to buy insurance or pay a penalty starting in 2013. He’d likely qualify for government subsidies to help him buy a private policy.
The Kaiser Family Foundation estimates someone at Dunn’s income would probably pay $600 to $800 a year for a policy, with government subsidies covering the rest.
The bill would limit his premium costs to a share of his income, possibly as little as 4 percent to 6 percent of that income, if he makes less than $20,000.
Still, that doesn’t kick in until 2013.
Dunn said $50 a month for health insurance would be “completely doable,” and that he’d appreciate any help the government could offer to help him afford health coverage.
Yet he also said he feels like he has the freedom to look for a better job that might offer coverage, between now and 2013. “A lot of people don’t have that option,” he said.
Kathy Dunn said she likes the idea of requiring people to pay a certain percentage of their income for health insurance, in order to keep their costs affordable. But she also asked why the program wouldn’t kick in sooner than 2013.
“For people in lower-income situations, it should be immediate,” she said. “For (Eric), that’s another $8,000 to $10,000 he’ll pay for health insurance (until 2013).”
Until reform arrives, life is a 'crapshoot'
Ken Minow, 52, Miles City
Ken Minow, who’s single, runs his own auto repair shop in Miles City and hasn’t had health insurance for more than 20 years.
Almost five years ago he had gastric-bypass surgery and has since lost 220 pounds, or half his previous weight. Because of the recent surgery, health insurers have told him he’s not insurable, or quoted him huge prices like $1,200 a month, he said.
He’s also still paying off a $12,500 medical debt from three years ago, when he had blood poisoning and had to spend several days in a Billings hospital.
Minow might be eligible next year to buy insurance through the new “high-risk” pool for people with pre-existing health conditions, as created by the Baucus bill. Yet, as explained earlier, it’s not known yet how much the coverage would cost or what it would cover.
Starting in 2013, Minow would be able to shop for health insurance through the new Health Insurance Exchange, a government-created electronic shopping center for policies that have minimum benefit levels. He could not be denied coverage or charged a higher price because of any pre-existing condition or surgery.
The Kaiser Family Foundation estimates Minow could pay as little as $2,100 a year for the policy, after government subsidies cover a share. Depending on his income, the cost could increase to $3,000 to $4,000 a year, for a policy with decent coverage.
Minow said he can probably afford up to $300 a month for health insurance, given his income. If reforms offer a policy for that amount or less, “that would wonderful,” he said. He also said he wouldn’t mind waiting the four years before those reforms kick in.
Until then, however, Minow said he’d probably go without coverage: “I’d continue to do the crapshoot.”
Young and healthy for the moment – but hoping nothing bad happens
Andrea Martin, 28, Helena
Andrea Martin had health insurance through a waitressing job until this fall, when she returned to school to study for a nursing degree. She had to cut back her hours at the restaurant to 10 hours a week, making her ineligible for the restaurant’s health plan.
She’s working 20 hours a week at two part-time jobs and attending school, and said she can’t afford health insurance.
The Baucus bill wouldn’t do anything to help Martin get coverage now, because the only things affecting her – expansion of Medicaid or government subsidies for insurance – wouldn’t take effect until 2013.
By then, Martin said she’d like to have her degree and be working as a nurse – somewhere, she hopes, that offers insurance as part of the job.
Until then, Martin said she’ll have little choice but to go without health insurance. Martin had Hodgkin’s lymphoma as a teenager, and is supposed to get periodic electro-cardiograms, but said she can’t necessarily afford it.
Martin said she feels frustrated when she hears that health care reform won’t do much to help people like her – at least not now.
“I feel like … I never really know what the truth is any more,” she said. “Everybody says they’re going to make health care better, but what does that mean? For who? For the people? For insurers? For employers?
“I just hope that nothing bad happens to me. I’m young and I’m healthy, but if something major were to happen to me, I’d be in big trouble financially. … I just try to exercise, eat well and take vitamins, and hopefully I don’t get sick.”