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VOL. 7 | NO. 14 | Saturday, March 29, 2014

Caught in the Middle

Many concerned with securing right health coverage

By Don Wade

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Even before the Affordable Care Act came along, Deborah Casey was living between a logistical rock and an economic hard place. Casey, a 61-year-old widow, draws a monthly Social Security check based on her husband’s earnings. She works part-time for Shelby County (no benefits), and to continue receiving the same amount in that Social Security check, she has to keep tabs on how much she makes. This is exactly how someone who wants to provide for herself winds up on a “fixed income.”

Recently, Casey was sitting in the waiting room at the Church Health Center’s walk-in clinic. It was an unseasonably warm day, but just a few days earlier she had fallen on the ice. She still had various pains. Waiting hadn’t made them go away.

Senate Minority Leader Mitch McConnell of Kentucky points to the pile of documents that comprise the controversial – and cumbersome – Affordable Care Act.

(AP Photo/Manuel Balce Ceneta)

She didn’t have health insurance. She, was, however, a regular patient at Church Health Center; to be a regular patient there one typically must work at least 20 hours a week and not have health insurance. And the federal Affordable Care Act law, commonly known as Obamacare, had her worried.

In almost all cases, the law requires any American who meets certain income-based criteria to have health insurance if not eligible for Medicare or Medicaid (Tennessee is one of the states that has not expanded Medicaid).

Casey is too young for Medicare and she was not eligible for Medicaid. So she was going to be required to purchase health insurance and she had done some preliminary research, checking out the marketplace exchanges at HealthCare.gov.

“The exchanges were set up to provide insurance for those who don’t get it through their employer, through Medicare or through Medicaid,” said Teresa Waters, professor of preventive medicine and a health economist at the University of Tennessee Health Science Center. “If you’re low income, the exchanges provide subsidies specifically for individuals who make between 100 percent and 400 percent of the federal poverty line.”

For 2013, the poverty line for an individual was $11,490. For a family of four, it was $23,550.

With the March 31 enrollment deadline bearing down, Leah Newsom, a health care navigator at the Memphis Community Development Council, has been spending six days a week trying to help people figure out what level of marketplace insurance plans will work best for them (more on this later).

But the way the 2010 law is written, subsidies are not necessarily available on an equitable basis. For example, Newsom says anyone whose income is just above the federal poverty line might be able to get a “very affordable plan.”

However, people who fall just below the poverty line can’t get subsidies (assistance) to pay for a plan. In theory, she says, people in this category were going to be covered by the expansion of Medicaid.

Because that didn’t happen in Tennessee, Deborah Casey’s place between that logistical rock and economic hard place has gotten tighter.

“I’m getting nervous,” she said. “March 31 is coming right up.”

Casey says she can’t afford even a $200-per-month premium. Anyone who is required to purchase health insurance – and maintain it – but doesn’t will be assessed a penalty. For 2014, that’s 1 percent of their income or $95, whichever is greater. Penalties increase each of the next two years.

This year, she may just pay the penalty. Financially, that’s probably the smarter play.

That’s what another Church Health Center patient, Leonard Jackson, 49, is going to do. A part-time electrician and a pastor in Frayser, Jackson is facing knee replacement surgery. Through the Church Health Center’s partnerships in town, the cost of his surgery will be mostly, if not entirely, covered.

He has a wife and two children, ages 20 and 24. No way can he do better by purchasing one of the marketplace exchange plans. So if his penalty is $95, or even a few hundred dollars, he’ll make that trade.

“Amen,” Jackson said.

But Casey is bothered by the fact that, technically, she would be in violation of the law if she does not buy insurance.

“Of course,” she said. “And the IRS is all in it.”

Said Newsom: “You’re breaking the law, but not in the sense that you’ll get a knock on your door and be hauled off to jail.”

Which is some comfort. But not a lot.

“This is not what I thought this program was going to be all about,” Casey said. “I’m just caught in the middle. I’m sure I’m not the only one.”

She’s not.

But there is an irony to her story: Deborah Casey spent 30 years as a social worker.

Law is big, cumbersome, confusing

Rare is the person who has attempted to read the 25,000-some pages of the Affordable Care Act.

“It’s about 10 feet high when you stack the pages on top of each other,” said Tim Finnell, a certified health care reform specialist and the president and founder of Group Benefits LLC.

“It’s unintelligible,” said Dr. Scott Morris, founder and CEO of the Church Health Center.

Dr. Scott Morris: “What people don’t realize is that with the advent of Medicare and Medicaid in 1965, we actually came close to having universal health care.”

(Memphis News/Andrew J. Breig)

So, by the time people reach health care navigator Leah Newsom’s desk, they may be in possession of more fiction than fact. They’ve heard some mix of truths, half-truths and total fabrications about the health care law from friends and family. Maybe they’ve read about it or watched various TV media reports that, depending on the source, may have been washed, rinsed and dried by someone advocating for one political party or the other.

“Some people come in feeling this is a negative situation,” Newsom said. “People come in already angry and frustrated and don’t expect to get anything positive out of the experience. For some, there is a feeling of being forced into this because the law is you have to have insurance. And the other thing is, it’s not free.”

Jackson looked into it just enough to say with confidence, “It’s a little bit confusing.”

Said Waters: “The law became more complicated because of a lot of pushing and pulling in Washington. But health care is complicated. It’s both.”

Morris says there was a day and time when it wasn’t so complicated. Morris will be the keynote speaker at The Daily News Publishing Co. Inc.’s Health Care Reform Seminar at 3:30 p.m. Thursday, April 3, at the Memphis Brooks Museum of Art Auditorium.

“What people don’t realize is that with the advent of Medicare and Medicaid in 1965, we actually came close to having universal health care,” Morris said. “Because at that point, people either had private health insurance from their job, Medicare if they were over 65, and they had Medicaid if they were poor.

“It was at that point that signs went up in doctors’ offices all over the country that said, ‘Payment is expected at the time of service.’ Prior to that, one-third of every doctor’s practice was expected to be charity care.

“In 1965, that changed,” Morris said. “People were expected to have a third-party payer. But between 1965 and when Church Health Center opened in 1987, we went from close to universal health care to 26 million uninsured Americans. That was a terrible thing. In 1987, the lion’s share of those were the working poor.”

Morris says the situation has worsened, citing the 2010 Census that put the number of uninsured Americans at 50 million.

“The real number is probably 60 million,” he said. “Nobody counts the immigrants. Politically, on both the left and right, the immigrants don’t seem to matter when it comes to health care even though they’ve been building houses in East Memphis for 20 years. If you don’t have a green card and you’re terribly sick, you’re going to be told to go back to Mexico.”

All of that makes for good discussion, and there will be a panel discussion on health reform as part of the April 3 seminar. But it’s all above the clouds to the people Newsom sees.

Her job is to help people understand a tiered plan that somewhat borrows from the Olympic model, with the best plans being platinum, the next-best gold, then silver, bronze and, in Tennessee, two catastrophic plan offerings available to people under age 30 and to those who fell in the “Medicaid gap” and could not get subsidies.

As of 2011, 18.2 percent of Shelby County’s population was without health insurance. Statewide, about 162,000 uninsured adults (19 percent of the uninsured in the state) who would have been eligible for Medicaid if Tennessee had expanded it, fall into the coverage gap.

In Tennessee, Newsom says there are more than 70 plans on the menu, each with variables such as premium, deductible, copay, approved providers and out-of-pocket costs for such things as doctor’s office visits and prescriptions.

“I have a headache every day after work,” she said, albeit laughing. “But I enjoy helping people. I can finish a basic application in 30 minutes. Picking out a plan and explaining insurance to consumers can take an hour to three hours. Going through 72 plans is cumbersome to say the least. I tend to have three to five visits with people.”

Newsom offers up one specific silver plan offered by BlueCross as an example of what someone might expect to pay: “If you’re right above the cut-off, and depending on your age, you’d be looking at anywhere from $5 to $45 a month as a premium, $0 deductible (depending on income), and $550 out-of-pocket maximum. That’s a low out-of-pocket max.”

But Waters worries about people who can only afford the cheapest plans. Bronze plans only pay 60 percent of medical costs.

“The bronze plan is bare-bones and has a higher deductible,” she said; this could result in a peak $6,350 out-of-pocket maximum for individuals and $12,700 for families. “And I look at this as an economist. The penalties are small enough they’re not going to change some people’s decisions. At 40, you realize you need health insurance. When you’re 26, you don’t want to pay for health insurance. Somewhere in between, that decision changes.

“Frankly,” Waters said, “it’s young people that we need in the insurance pool to keep the pool stable. You must have low-risk people to offset the people with high-risk expenses. You hear people say they don’t want to pay for somebody else’s health care, but later on somebody will be paying for you.”

Allison Jones, a social work supervisor at Church Health Center, also helps people through the process.

“It’s stressful for most people,” Jones said. “For one, they have to fit it in their budget. And two, they have to change their doctor.”

For some, the more they investigate the plans the better the news. They can afford a stronger plan than they imagined.

“I get lots of hugs,” Newsom said. “I’ve cried for joy with people.”

For others, the news is devastating. They’re in the gap. They get no assistance. Some people sign up anyway, even though their incomes and the monthly premiums don’t mesh.

“By the end of the year, you have to decide between paying your health insurance or paying your rent,” Morris said.

In his view, there are actually gaps in coverage for all. For instance, no dental or vision care for adults and only limited coverage for behavioral issues. He says a lack of dental care is an economic issue for poor people, telling a story about a man who literally tried to fix the gaps between his teeth with Super Glue in preparation for a job interview.

“In America, how did we get to the point where someone tries to Super Glue their teeth together?” he asked. “That’s immoral.

”I have no idea where we’ll end up (with this law),” Morris added, “but the thing I’m 100 percent sure of is Jesus said the poor will always be with you and he was right.”

The one thing on which everyone seems to agree: more change, and more complications, are inevitable.

Beyond that, there is this rosy reality: All health insurance is a lottery based on worst-case scenarios.

“Everyone, in a given year, has a small chance of getting cancer,” Waters said. “Those bronze plans are bare-bones, but it is insurance and will protect you. Some people think that, `Well, if I get really sick, the hospital will have to take care of me.’ Well, yes and no. You can tell a story of many people who have gone bankrupt because of medical bills. It happens. And these insurance plans will protect you from that.

“You can’t buy these plans later, when you get sick. That’s what this open enrollment is. This is the time, not three months from now.”

Mitch Graves, president and CEO of Health Choice LLC, a physician hospital organization (PHO) that is a joint venture between Methodist Le Bonheur Healthcare and MetroCare, says with major change comes major opportunity.

“We’ve got some of the highest-cost health care in the world, yet our results are not any better than some countries that spend less,” Graves said. “Change is inevitable in the health care world. We’ve been focused on volume and now we’re becoming a value proposition – getting people well and outcome measures.”

And for that, the patient bears some responsibility, too – no matter how much he is or isn’t paying for his health insurance.

“Most people take their car in to get the oil changed and the tires rotated,” Graves said. “Some people don’t care for their bodies as well as they take care of their car.”

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