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.
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.
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?”
‘One diagnosis away'
Fran Britton won't forget the day she passed her driving test. She was 16, had already flunked once and was nervous she would flunk the second time.
She was in the car, and the driving instructor was having trouble telling her where to turn because several of the streets were blocked off.
The instructor just told her, “Forget it, you passed.”
It wasn't until several years later when she was reading a “This Day in History” that she found out — President Lyndon Johnson was down the road from her driving test location, signing the Medicare bill at the Harry S. Truman Library and Museum near Kansas City.
Almost 50 years later, she's looking to sign up.
“Everybody was saying, ‘Medicare is going to ruin medicine, and it will be this, that and the other thing,' and you know, it saved so many elderly people from horrible existences, but it was also probably part of the reason health care costs have gone up,” she said.
Britton's husband has saved $600 per month in health insurance costs since joining Medicare. And Britton, 64, only has a few months to go before she's eligible. Until then, she plans to sign up for the other government-run insurance program, the health insurance marketplace.
Britton pays $929 per month for a plan with a $500 deductible. She has calculated that she could save about $500 per month on the exchange. She's eligible for Medicare in June.
Shortly after the U.S. Supreme Court upheld a majority of the Affordable Care Act, Britton cried tears of relief.
Britton had thought the law didn't have a chance of making it through the court. Before and since President Barack Obama signed the law into action in March 2010, a political uproar had been boiling in the U.S. over the law's constitutionality.
Britton said she wanted better for other families.
“We always thank the Lord that we were always able to, even though it was expensive, save money and afford a baby, and fortunately we never had children with drastically horrible things where you would have bankrupted a family,” she said. “But the reality is you always feel like you're one diagnosis away from being that family, and I think it's heartbreaking.”
Brink of bankruptcy?
Blatt, of the Oklahoma Policy Institute, a nonpartisan think tank, said although people will pay a premium of some size, it will be significantly less than what many people paying for individual policies are used to.
“We know medical bills are the single largest cause of financial bankruptcy,” Blatt said. “Everybody is one accident, one illness away from financial ruin.”
As recently as 1981, only 8 percent of families filing for bankruptcy did so in the aftermath of a serious medical problem, according to a study published in 2007 in the American Journal of Medicine.
That number has since exploded. In 2007, illness or medical bills contributed to 62 percent of all bankruptcies, according to the study.
This week, Hugh Meade and his wife, Tammy, will meet with a bankruptcy attorney, in part because of their debt from a medical emergency.
Tammy Meade had an emergency back surgery in 2007. A disk in her spine had prolapsed and was crushing the nerves in her spine. She couldn't walk.
The surgery cost $30,000, and six years later, they continue to get bills every month and calls most days on it.
“There's every possibility that something could happen to me, and if it happened again, I'm sure we'd be declaring bankruptcy — there's no way around it,” Hugh Meade said. “But declaring bankruptcy costs money, too. You have to pay the lawyer, and I don't know if we can afford to declare bankruptcy.”
Meade plans to look at the prices of insurance coverage plans through the marketplace.
He's still uninsured while his wife is on temporary disability. They pay $140 per month for an individual policy for their son. When they first got the plan, it was $70 per month.
Meade stopped looking for individual coverage for himself about five years ago.
“The reason I stopped looking into it is because every time I looked, to cover just me, not including my wife and child, was often somewhere in the $600-a-month range, and that's very nearly what my mortgage is,” he said.
Subsidized coverage for him in the health care exchange would be less than $100 a month.
Meade owns Oddfab Design Studio, where he custom-builds signs and does other carpentry work. He regularly works with power tools and welding equipment. Meade said finally getting insurance will give him a sense of relief.
“Every time I come in here and start using power tools, I think about it,” Meade said.
“I've had, for several months, really bad sciatic pain in my lower back and down my right leg ... by the time I go to bed at night, it's excruciating. I don't go to the doctor because I don't know what he's going to say, and once he writes down in that folder that I have a condition, and it might be chronic — if the Affordable Care Act goes away, I don't want a pre-existing condition before I get insured.”