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.”
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.
Medicaid
Matters:
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.
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.
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.
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.
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.
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.
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
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
Floyd & Joe
TOGETHER WE CAN
FIND A CURE . . .
By . . .
“Changing the
Conversation”
"Health Care For All"
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