All I want for Christmas is good health insurance
The Affordable Care Act's (ACA, Obamacare) open enrollment period ends on Monday, Jan. 15. If you have no health insurance, are aging out of Mom’s or Pop’s health plan, or question the health part of your health plan, read on.
Six months ago, Moses, 62, and his wife, April, saw me in the free clinic. He was discharged after a stroke. He only wanted one thing, a prescription for varenicline (Chantix), a drug that helps stop smoking.
Moses hadn’t touched a cigarette, was doing well, feeling well. He could lift his right arm above his head but needed time to say his words. His wife, April, was quiet and attentive.
Despite the good news, I was edgy, waiting to ask the “question.”
Before I saw him, I reviewed his record and was surprised by a finding on his lung scan. First, a lung scan isn’t routine for stroke workup. Worse: it showed a good-sized mass. Moses didn’t bring up the mass.
“Did anybody mention a lung mass?” I asked.
The answer was yes. And they asked him to get a PET scan and bunch of other tests. With a PET scan, doctors can find spots in our bodies that are burning excess energy – like cancer. Think: cops can locate a marijuana grow house using a heat sensor.
“When’s it scheduled?” I inquired.
“We called, but nobody called us back,” April said.
That worried me.
To start, Moses hadn’t had health care or health insurance for 10 years since his last factory job. As a hotel manager, April has health insurance through her work. Her health insurance costs $85 per biweekly paycheck, but to add Moses, it’s an additional $520 – not possible with their tight budget. They missed the Medicaid cutoff by $150 per paycheck.
April thought he was doing fine, but Moses, a philosophical optimist, admitted he didn’t say much when not feeling well, because: “Things have a strange way of working out.”
Our office got to work. First, we contacted our volunteer pulmonologist, who called a thoracic surgeon, who called nuclear radiology to set up the scan.
Moses signed up for ACA. The parts that work:
1. He was able to enroll in ACA in the middle of the year because of his recent stroke. Under ACA’s special enrollment, changes in health, financial, or family situation could qualify for last-minute enrollment.
2. He pays $91 monthly for a robust silver health plan that normally costs $906 monthly (annual saving of $9,780). The average cost of ACA for an Ohioan is $114 per month.
3. In this plan, Moses has a maximum out-of-pocket expense of $3,000 per year, which means his insurance will pay for everything after he pays $3,000 for the year.
4. His primary care visits are free (lower tiered plans may have copays). April found a nice Primary Care Physician who is “laid back and straightforward.”
5. Because all preventative services are free (see the listing at healthcare.gov), Moses got all his overdue vaccines – including multiple pneumonia vaccines – for free.
6. A PET scan costs between $3,000 and 12,000. Under the insurance, Moses’ copay is $240.
Six months after his stroke, I called to see how they’re doing. I wish I had a happy story, but I don’t. They haven’t been able to get any tests.
By now, Moses’ speech is fluent, his right arm is “99%” normal. Still not smoking.
But his “final notice” and “seriously past due” bills (prior to ACA coverage) are flooding in. April figured they owed $8,000 for the 4-day stroke hospitalization. They’re working on a payment plan with the hospital. April works 50 to 65 hours a week, and they’re unable to front the $240 for the PET scan or any other tests.
To convince them the gravity of the situation, the pulmonologist said, “It’s cancer,” based on the CT finding. April is wracked with guilt and cries daily.
To help, his PCP has scheduled his tests after the new year, so they have one $3,000 annual deductible to deal with. I believe Moses’ “Things have a strange way of working out.” But call ACA’s 24/7 helpline and find out for yourself.