HEALTH INSURANCE

Why ‘Obamacare’ was necessary

 
 
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MCT / MCT

ruthmarcus@washpost.com

This would be a good time to remember Karen Tumulty’s brother.

As the healthcare debate raged in March 2009, Karen wrote a Time magazine cover story about her brother Patrick’s insurance nightmare.

Patrick, then 54, had done what seemed to be the right thing. Then a $9-an-hour administrative assistant in San Antonio, he bought coverage on the individual market, diligently paying monthly premiums to Assurant Health for six years.

The policy carried a $2,500 deductible, with no allowance for preventive care. So Patrick, who struggles with Asperger’s syndrome, put off going to the doctor, despite increasing fatigue and high blood pressure. Eventually, Patrick discovered the cause: His kidneys were failing.

That is where insurance came in — theoretically. “Unexpected illnesses and accidents happen every day, and the resulting medical bills can be disastrous,” warned the website of Assurant Health, which sold Patrick his policy. Its policy, Assurant promised, “provides the peace of mind and healthcare access you need at a price you can afford.”

Except it didn’t. Assurant balked at paying Patrick’s claims. In just four weeks, he had racked up more than $14,000 in bills. “And that was just to figure out what was wrong with him,” wrote Patrick’s younger sister, now my Washington Post colleague. “Actually treating his disease was going to be unimaginably more expensive.”

Assurant’s excuse? Patrick, hoping he’d find a job that offered insurance, had bought a series of six-month policies. Each one treated him as a new customer. Although Patrick’s kidney disease wasn’t diagnosed until July 2007, Assurant, scouring his medical records for a money-saving out, cited test results from eight months earlier. Bingo! — pre-existing condition. No coverage.

Patrick Tumulty is Exhibit A on the need for Obamacare and the importance of putting into context the furor over if-you-like-your-policy-you-can-keep-it-gate.

This is not to excuse President Obama for peddling a misleading claim or to excuse those of us in the news business for failing to press him on it earlier. The president’s weaselly rewording of his pledge — “What we said was you can keep it if it hasn’t changed since the law passed” — is insulting to anyone who heard what he had said, repeatedly.

Yet there was always an unstated asterisk to the presidential promise. Existing plans would be grandfathered in and not subject to the heightened requirements (i.e., better benefits) of the Affordable Care Act.

Because plans inevitably change, that grandfathering promise was always illusory. Just three months after the law passed, the administration estimated that between 39 percent and 69 percent of employer-sponsored plans would lose grandfathered status by the end of 2013.

On the individual insurance market, from which most of the yelping now emanates, the grandfathering promise was even sketchier. The administration estimated that between 40 percent and 67 percent of such policies are in effect for less than one year — by definition, not grandfathered. Since policies change even for those who hold on to coverage, the administration acknowledged that the share of plans losing grandfathered status would be even higher.

So where does that leave the Patrick Tumultys of the world? He probably wouldn’t have been able to keep his policy — but as he discovered, it wasn’t worth keeping.

Shopping for insurance today, he wouldn’t be denied coverage, or charged vastly more, because of his expensive pre-existing condition. His insurer wouldn’t be able to wriggle out of paying bills because of that condition. He would have been able to afford a checkup (with no-copayment) that might have detected his disease earlier. His policy would cover his expensive prescription medications. He wouldn’t have to worry about bumping up against annual and lifetime limits on benefits.

Karen reports that Patrick’s kidney disease is mostly stable. He was lucky enough to obtain bare-bones healthcare (no dental or vision) through a local program.

But Patrick remains a disturbing illustration of gaping holes in the social safety net.

Texas Gov. Rick Perry chose to opt out of Obamacare’s expansion of Medicaid to cover impoverished childless adults like Patrick. [Florida has also opted out.] Patrick could purchase insurance on the new exchanges but — because of Perry’s Medicaid declination — he would have to pay the full premium. As Karen noted, “He is, paradoxically, too poor for subsidies.”

Meanwhile, Patrick is out of work. His unemployment compensation ran out long ago. Despite his medical problems, he’s been unable to qualify for Social Security disability.

So, yes, this is an infuriating moment in the implementation of Obamacare. But as you steam, stop and think about people like Patrick Tumulty — and where they’d be without it.

(c) 2013, Washington Post Writers Group

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