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The personal choices of health care: Experiences shape perspectives of Oklahomans

Oftentimes, the debate over health care and the Affordable Care Act focuses on the politics and rhetoric. Often forgotten are the people affected, day to day, by the health care choices they have to make for themselves and their families, as these Oklahomans' stories reveal.
by Jaclyn Cosgrove Published: September 22, 2013

Kim Pearce was so close to canceling her family's insurance policy.

It's still scary to think how close. Because, in one week, her son had four doctor's visits, a trip to the emergency room and a $16,000 emergency flight from Stillwater to Tulsa.

“For whatever reason, I think it was definitely a God thing that we did not cancel that policy, because within two weeks of moving here, you end up on that helicopter,” Pearce said.

This experience taught Pearce that the insurance premium must always be paid. No bargaining allowed.

Whether her family will have insurance is not an option, but what they have to pay for that insurance is.

Pearce and her husband are among thousands of Oklahomans who might enroll in an insurance plan through the health care marketplace.

Beginning Oct. 1, Oklahoma residents will be able to shop for federally subsidized insurance in a marketplace where private insurance companies will post their rates.

David Blatt, director of the Oklahoma Policy Institute, said for many Oklahomans, having access to insurance will lift a major burden.

“With the Affordable Care Act, with all its complexities and imperfections, it's going to mean for hundreds of thousands of Oklahomans, they will be able to, many for the first time, get a quality health insurance plan at an affordable rate,” Blatt said.

‘Million-dollar babies'

Pearce's adventure through the medical system began when her son, who was 3 at the time, cut his mouth. He bled off and on over a five-day period.

After he got to the hospital in Tulsa, he was diagnosed with hemophilia, a rare bleeding disorder that hinders the body's ability to clot blood.

Hemophilia is one of the most expensive chronic diseases to treat. For example, Pearce's son Gavin, now 8, takes a medicine that is about $1,700 per dose. Luckily, her insurance and a pharmacy assistance program pay the $27,000 monthly cost.

But children with hemophilia are often dubbed “million-dollar babies” because of how quickly they hit their lifetime insurance coverage caps. The Affordable Care Act brought some reform to this policy, but Pearce still worries about how it will affect the way insurance companies cover Gavin's medicine.

His medicine is considered a specialty drug, and she worries that, after Jan. 1, insurance companies might change how and which specialty drugs they'll cover.

For example, an insurance company could choose to cover a different type of hemophilia drug, which might not work as well for the hemophilia sufferer.

“Now that these marketplaces are open, we can still keep this insurance policy,” she said. “We're just going to need to figure out what will be the best route for us.”

While Pearce is uninsured, her husband and two of her children at home have a plan that costs $750 per month.

Pearce's household income is about $65,000. Financial support, in the form of a subsidy, is available for families that fall between 100 percent and 400 percent of the federal poverty level.

Pearce's family is at 276 percent. Under the exchange, her family might pay an estimated $9,869 for a silver plan and potentially qualify for a subsidy of $4,146, according to the Henry J. Kaiser Family Foundation subsidy calculator.

Potentially, Pearce could pay $5,723 per year for coverage, or about $477 per month. Under a silver plan, the plan pays for 70 percent of expenses in total covered benefits while enrollees are responsible for the rest, according to the Kaiser foundation.

The estimate doesn't account for differences based on where a person lives, which can have a significant impact on marketplace prices and offerings.

Transparency issues

Jonathan Small argues that through the marketplace, more people will be insured in a health care system that lacks price transparency.

“Think about higher education,” said Small, fiscal policy director at the Oklahoma Council of Public Affairs. “We have dumped massive amounts of state, local and federal money into higher education, but yet, it has caused tuition, fees and higher education spending to increase tenfold over the last 40 years, and that's basically what the health care law does. It does very little to make cost transparent for patients and pumps a lot of money into a broken financing system for health care.”

Small said Oklahoma already ranks poorly in the number of primary care doctors per capita. The increased access to care will further exacerbate the wait time for people getting in line to see a doctor, he said.

The No. 1 priority should be getting costs under control, he said.

“We've got to ask a serious question of why entities that have a mission statement ‘to be the healing hands of Jesus by providing care to the poor and powerless' or missions similar to that are in a position where they're having an advertising war during the OU football games and able to buy practice facilities for professional teams,” Small said. “How are those entities in the position that they're putting people into bankruptcy?”

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by Jaclyn Cosgrove
Medical and Health Reporter
Jaclyn Cosgrove writes about health, public policy and medicine in Oklahoma, among other topics. She is an Oklahoma State University graduate. Jaclyn grew up in the southeast region of the state and enjoys writing about rural Oklahoma. She is...
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