Chapter 25 Do you have money to Survive

Chapter 25

  Do you have money to Survive?

Floyd & I were back on the Delta yesterday . . . but every nautical mile we traveled . . . we reflected on our promise to make sure that we . . .

"Left a wake behind us, that we would want others to leave for us."

So today, we stayed at our berth and continued our  “online research”  and came upon a “report , titled Spending to Survive released by the American Cancer Society and the Kaiser Family Foundation in February 2009 that examines the holes in the health insurance system that cancer patients face even when they are insured.”

Spending to Survive:

Cancer Patients Confront Holes in the Health Insurance System

By Karyn Schwartz and Gary Claxton

Kaiser Family Foundation

Kristi Martin and Christy Schmidt

American Cancer Society

Executive Summary

Keith always made sure he paid for health insurance and got annual physicals. But now that he is fighting stomach cancer and paying high health insurance costs, he had to cash out his 401K and has amassed thousands of dollars in medical debt.

Jamie had health insurance through her job at a nursing home, but once she was diagnosed with breast cancer, she quickly exceeded her plan’s annual cap and now has about $30,000 in debt. She sometimes receives three calls a night from collection agencies regarding her medical debt.

Thomas’ prostate cancer was diagnosed early and eradicated with surgery in 1999. Due to his past cancer diagnosis, he had trouble finding coverage after he retired, and he now pays about one-quarter of his income toward his health insurance.

In 2008, approximately 684,850 new cases of cancer were diagnosed in people under the age of 65 in the United States.1 One study estimated that the majority of cancer patients under the age of 65—70 percent—have private health insurance. Despite having private insurance, some cancer patients—like those described above—are not always protected from high health care costs. Because cancer treatment can be very expensive and because patients and survivors often need long-term treatment and monitoring, they are among those who are likely to have difficulties navigating the U.S.health insurance system. This report highlights the issues cancer patients and survivors face as they try to find and maintain affordable coverage that enables them to access the care they need.

These three people and the 17 others featured in this report are among the more than 20,000 people who have called the American Cancer Society Health Insurance Assistance Service because they are having trouble finding adequate and affordable health insurance or are struggling to pay for health care despite being insured. These stories illustrate five key findings about the current private health insurance system and how those with cancer and other serious diseases may be exposed to high financial burdens and, at times, may be unable to access care.

1) High cost-sharing, caps on benefits and lifetime maximums leave cancer patients vulnerable to high out-of-pocket health care costs. The various types of cost sharing and limits on benefits found in some insurance plans may quickly lead to high out-of-pocket costs once cancer treatment begins. Some of the people profiled in this report amassed more than $100,000 in medical bills, despite having an insurance policy throughout their treatment.

2) People who depend on their employer for health insurance may not be protected from catastrophically high health care costs if they become too sick to work. While cancer patients who are unable to work can usually continue their employer-sponsored insurance coverage for up to 18 months by paying the full premium, that additional cost can be a substantial burden since these patients are typically living on a reduced income. Some patients in this report have had to exhaust their life savings to continue their coverage once they could no longer work.

3) Cancer patients and survivors are often unable to find adequate and affordable coverage in the individual market. Cancer survivors in this report who have been in remission for years and have a good long-term prognosis still had trouble finding coverage or paid higher premiums in the individual market due to medical underwriting. Patients and survivors who lose their jobs, decide to change jobs, or otherwise lose their group insurance can be denied coverage in the individual market because of a cancer diagnosis and can ultimately be left uninsured.

4) While high-risk pools are designed to help cancer patients and others who are uninsurable, they are not available to all cancer patients and some find the premiums difficult to afford. Not all states offer coverage through high-risk pools, and when this coverage is available it remains much more expensive than most other plans in the individual market.

5) Waiting periods, strict restrictions on eligibility, or delayed application for public programs can leave cancer patients who are too ill to work without an affordable insurance option. When cancer patients are too sick to work, they may qualify for Social Security Disability Insurance income and, after two years of receiving this income, they can qualify for Medicare coverage. During this two-year waiting period, these patients are typically living on a reduced income and may not be able to afford private insurance coverage. Cancer patients with low incomes who are unable to afford comprehensive private insurance may not qualify for Medicaid due to limits on eligibility, leaving them without adequate, affordable coverage. While public programs, such as Medicare and Medicaid, are a crucial source of coverage for millions of Americans, limits on eligibility prevent these programs from providing a safety net for many cancer patients. Although many of the cancer patients in this report have limited incomes and high health care costs, none qualifies for public coverage.

This report demonstrates that even when people have private insurance, they may not be protected from high out-of-pocket costs if they are diagnosed with cancer. These costs, along with the cost of insurance premiums, can potentially force cancer patients to incur debt in order to pay for the care they need or forgo or delay lifesaving treatment. Cancer patients who are unable to work due to their illness are particularly vulnerable, since they may lose their employer-sponsored insurance.

It is impossible to determine exactly how many privately insured individuals in the United States are at risk for high out-of-pocket health costs. However, research indicates that a growing percentage of the population is already facing high out-of-pocket costs. Gaps in the current private health insurance system leave cancer patients and others with serious illnesses vulnerable even when they have coverage. Eligibility restrictions prevent public programs from reaching some of the individuals who are struggling to maintain coverage or pay for care in the private health insurance system. Addressing the holes in the current health insurance system will be key to providing the privately insured with economic security and access to health care in the face of illness.

Kaiser Family Foundation MARCH 2011

Medicaid Matters:

Understanding Medicaid’s Role in Our Health Care System

Medicaid, the nation’s public health insurance program for low-income people, now covers nearly 60 million Americans, including many working families, as well as many of the poorest and most fragile individuals in our society. Medicaid is the largest source of financing for nursing home and community-based long-term care, and it provides essential funding for the safety-net delivery system on which many Americans rely. Most Medicaid enrollees would be uninsured without the program. Medicaid is a counter-cyclical program; during the economic recession, it expanded as intended, assisting millions of people affected by loss of employment and health coverage and declining income, but also straining state budgets. To help states with their increased Medicaid costs, Congress provided them with temporary extra federal assistance. Under current budget pressures, some federal and state policymakers have proposed cuts in Medicaid as a way to ease them. This brief provides key information about the Medicaid program and its role in our health care system and state economies – background needed to ensure careful weighing of actions that would affect Medicaid and those it serves.

Who does Medicaid cover?

Medicaid covers 1 in 3 children. Medicaid is the largest source of health coverage for children. Most of the 30 million children covered by Medicaid are in families at or below the poverty level ($22,050 for a family of four). Medicaid benefits for children are comprehensive, with an emphasis on promoting children’s healthy development and maximizing their health and function.

Medicaid covers more than 1 in 3 births. Medicaid covers maternity and prenatal care for low-income women and more than 40% of all births. Medicaid coverage of pregnant women helps to ensure healthy mothers and healthy newborns.

Medicaid covers 8 million people with disabilities. Medicaid covers people with a wide diversity of physical and mental health conditions and limitations, and extensive and complex needs. Most of them lack access to private or coverage of services they critically need. Medicaid covers key health and long-term services and supports, including personal care assistance, transportation, and assistive devices that many need to maintain function and, in some cases, independence. The services Medicaid covers enable many individuals with disabilities to work.

Medicaid covers 1 in 4 poor nonelderly adults. Currently, Medicaid eligibility for adults is very limited in most states. In the median state, parents are not eligible unless they are below 64% of the poverty level ($14,112 for a family of four), and in most states, adults without dependent children are not eligible regardless of their income level, reflecting their exclusion from Medicaid prior to the passage of health reform. Due to these restrictions, almost half of poor working-age adults are uninsured. Under the Patient Protection and Affordable Care Act (ACA), Medicaid will expand in 2014 to nearly everyone up to 133% of the poverty level, reaching 16 million more people by 2019 – mostly, uninsured adults.

Medicaid covers nearly 9 million low-income Medicare beneficiaries. “Dual eligibles,” the low-income seniors and younger people with disabilities who qualify for Medicaid as well as Medicare, are among the sickest and poorest individuals covered by either program. More than half have income below $10,000 and most have substantial health needs. Medicaid covers Medicare premiums and cost-sharing charges for dual eligibles, as well as critical services – in particular, nursing home and community-based long-term care services – that are excluded or sharply limited in Medicare. These very poor, high-need beneficiaries account for almost 40% of all Medicaid spending.

What does Medicaid cover?

Medicaid covers comprehensive services for children. Medicaid’s benefit package for children, known as EPSDT, includes screening, preventive and early intervention services, as well as diagnostic services and treatment necessary to correct or improve children’s acute and chronic physical and mental health conditions. Dental and vision care important to all children, as well as services like physical therapy, personal care services, and durable medical equipment, which are particularly important for children with disabilities, are covered as needed under EPSDT. To ensure that low-income children do not face financial barriers to needed care, they are largely exempt from cost sharing in Medicaid.

This publication (#8165) is available on the Kaiser Family Foundation’s website @ www.kff.org.

Kaiser Family Foundation September 2012

Five Facts About the Uninsured Population

Nearly 48 million nonelderly Americans were uninsured in 2011, a decline of 1.3 million since 2010.

Decreasing the number of uninsured is a key goal of the 2010 Patient Protection and Affordable Care Act

(ACA), which will provide Medicaid or subsidized coverage to qualifying individuals with incomes up to

400% of poverty beginning in 2014. This brief provides basic facts that explain who the uninsured are

and the effects of being uninsured.

1)    Most of the nation’s 47.9 million uninsured have low- or moderate-incomes.

Individuals below poverty are at the highest risk of being uninsured, and this group comprises 38% of all

the uninsured (the poverty level for a family of four was $22,350 in 2011). In total, nine in ten of the

uninsured are in low- or moderate-income families, meaning they are below 400% of poverty. Health

insurance is expensive, and many cannot afford the premiums without sizable employer contributions.

In 2012, the average cost of employer-sponsored family coverage was $15,745.

2)    More than three-quarters of the uninsured are in a working family.

Uninsured workers typically are not offered insurance through their own or a family member’s

employer. Additionally, persistently high unemployment since 2008 has put many people’s employer sponsored coverage at risk. Meanwhile, many workers who are offered employer-sponsored coverage saw the cost of their share of premiums rise in the last year.

3)    Medicaid and the Children’s Health Insurance Program (CHIP) provide a key source of coverage for many low-income families who lack access to other affordable coverage.

Enrollment in public coverage has increased steadily in recent years reflecting the poor economy. In

2011, there were almost 47 million people below age 65 enrolled in Medicaid and CHIP, although many

low-income adults remain ineligible for the program. Even amid budget pressures, Medicaid eligibility

has remained stable due to the ACA requirement for states to maintain eligibility levels until the broader

coverage expansions take effect. The continued availability of Medicaid coverage has played a key role

in preventing more people from becoming uninsured during the weak economy, especially children.

4)    About one-quarter of uninsured adults go without needed care due to cost compared to only four percent of those with private insurance.

The uninsured suffer from negative health consequences due to their lack of affordable access to

necessary medical care. They are less likely than those with insurance to receive preventive care and

services for major health conditions—which leads to more serious health problems for many and

significantly higher mortality rates.

5)    Medical bills are a burden for the uninsured and frequently leave them with debt.

The uninsured often face unaffordable medical bills when they do seek care. When they receive care,

the uninsured pay for more than one-third of their care out-of-pocket and are often charged higher

amounts for their care than the insured pay. Most of the uninsured have low or moderate incomes and

have little, if any, savings; high medical bills can be an additional source of financial strain for families who are already struggling to make ends meet.

This publication (#7806-05) is available on the Kaiser Family Foundation’s website @ www.kff.org

Cancer Patients and Survivors: Their Experiences with Private Health Insurance
Name	Age	Type of Cancer	Type of Insurance	Insurance Issue
1	41	Lymphoma	Employer-Sponsored	Pre-existing condition exclusion caused treatments to be postponed
2	58	Ovarian cancer	Employer-Sponsored	Out-of-network doctors led to medical debt
3	58	Breast cancer	Employer-Sponsored	Annual benefit limits led to about $30,000 in medical debt
4	52	Breast cancer	Employer-Sponsored	Annual benefit cap led to medical debt and postponement of radiation treatments
5	24	Lymphoma	Employer-Sponsored	Had to continue working during cancer treatments in order to maintain insurance coverage
6	10	Leukemia	Employer-Sponsored	Close to reaching the policy’s $1 million lifetime maximum
7	40	Breast cancer	Employer-Sponsored	Minimal-coverage plan led to debt that eventually caused bankruptcy
8	44	Melanoma	Employer-Sponsored	Separate deductibles led to medical debt and a recommended scan was denied by insurer
9	52	Breast cancer	Employer-Sponsored	Taking on credit card debt to pay her deductible and co-payments
10	61	Breast cancer	Individual	Reached maximum benefits for radiation, can’t afford high-risk pool
11	61	Prostate cancer	Individual	Individual market insurance with rising premiums
12	56	Breast cancer	Individual	Caps on benefits led to medical debt
13	60	Colon cancer	Individual	Lost employer coverage when unable to work, trouble paying premiums and cost-sharing
14	47	Sarcoma	Individual	Caps on services led to medical debt
15	62	Prostate cancer	Individual	Paying high premiums due to past cancer diagnosis
16	62	Kidney cancer	Individual	Individual plan with no prescription drug coverage, not eligible for high-risk pool
17	53	Kidney cancer	COBRA	Unable to work, struggling to pay COBRA premiums
18	54	Stomach cancer	High-Risk Pool	Going into debt to pay for high-risk pool coverage after exhausting COBRA
19	45	Breast cancer	High-Risk Pool	Trouble paying high-risk pool premiums
20	46	Symptoms of leukemia	Uninsured	Uninsured after exhausting COBRA

How do we protect “cancer travelers” and their loved ones?

Floyd & I use the term “cancer travelers” because, unfortunately, not all people who have been diagnosed with cancer are survivors, but all are making the journey.

“We are all responsible for our wake and any influence it causes!”

"Leave a wake behind you, that you would want others to leave for you."

Til’ we chat again, 

Floyd & Joe

TOGETHER WE CAN FIND A CURE . . .

By . . .

“Changing the Conversation”

 "Health Care For All"