Gary's Story

This is the second of a 6 week series entitled, "Summer at the County Fair". It is a synopsis of 6 hours I spent meeting and speaking with people who were visiting a county fair in western PA. Over the next few weeks you will see the human faces that mirror our national statistics regarding the uninsured and underinsured. Thanks to the Pennsylvania Health Access Network (PHAN) for their assistance in this series

“I hate glass!” Gary stated with an affirmative tone when I first met him at a county fair in western Pennsylvania.  I chuckled with an overtone of confusion waiting what I thought would be a punch line.  “In fact, if you come to my house, I don’t have anything made of glass anymore,” he explained.  He continued to describe the journey which led to his fractured relationship with glass and it didn’t include a punch line.  In fact, Gary was one of dozens of employees recently laid off from the local glass company when it moved its plants to Venezuela.  Textiles, steel or glass, you name it.  The abandoned structures of the Pennsylvania manufacturing industry litter the landscape.  If you look hard enough at the rusted shells of the factories that used to harbor tireless production, you can see the ghosts of generations past and their lifestyle that has not withstood the test of time.

His relationship with glass wasn’t the only thing left shattered after the plant departure.  His sense of security in being able to take care of his family’s health needs is also fragile.  While he is picking up the pieces of his career by going back to trade school for working with heavy machines, his only opportunity for healthcare security comes from the very expensive COBRA plan.  While COBRA allows him to maintain his prior health insurance plan, it is costing Gary and others in his situation over $14,000 a year.  For many, this is a financial impossibility when you don’t even have a job.  In 2009, 57% of unemployed adults were without health insurance.[1]

Gary’s story is not unique in our changing global economy.   There are many “Garys” out there, individuals that embody the spirit of American manufacturing trying to survive in a time that has left them behind.  While the plants leave to thrive over-seas, they also take the health insurance plans the workers depended upon.  Times have changed and the Patient Protection and Affordable Care Act will now allow our workers to adapt to it.  In 2014, laid off workers will be able to access high-quality health coverage on a new marketplace called the individual exchange.   This new marketplace will replace COBRA and have strict guidelines for essential benefits.    Additionally, depending up on their income, they may also qualify for premium tax credits  in order to cover their costs.  Gary and others like him can also expect to enjoy the other standard benefits guaranteed by the Patient Protection and Affordable Care Act such as preventive care, medical loss ratio, basicpatient protections and rate review.

After leaving me with his final words about glass and health insurance, Gary was eager to get on with the festivities that a county fair has to offer on a July afternoon.  He quickly disappeared into the crowd.  This rapid departure seemed to be the personification of the person I briefly met.  Gary, the portrait of an American worker, has had a long history of picking up the pieces, reinventing himself, and moving on.

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[1] Schwartz, K., Streeter, S., Kaiser Family Foundation. Kaiser Commission on Medicaid and the uninsured.  Health Coverage for the Unemployed. June 2011

Tyler's Story

This is the first of a 6 week series entitled, "Summer at the County Fair".  It is a synopsis of 6 hours I spent meeting and speaking with people who were visiting a county fair in western PA.  Over the next few weeks you will see the human faces that mirror our national statistics regarding the uninsured and underinsured.  Thanks to the Pennsylvania Health Access Network (PHAN) for their assistance in this series.

Artwork by: Don Perino

Early afternoon at a county fair has a flavor of resurgence.  Clean hay in the stables, tidied sidewalks, vendors opening their panels.   With the sun high in the sky, the rejuvenated crowds begin to dwindle in.  All is fresh and ready for a new day.  Just before his shift at the steak sandwich concession, I met Tyler, a blond-haired 22 year old from Venango County, PA.  Behind his timid approach, Tyler’s captivating blue eyes and shy smile told the eternal tale of youth and hope.  His image portrayed someone ready to embrace the future, but was in fact disguising an old soul. 

 While other 22 year olds were out relishing in the immortal fruits of youth, Tyler was talking about health insurance.  He has been uninsured for over 4 years, since he turned 18.  His employer does not offer health insurance and for Tyler, a full time worker, it is simply unaffordable on an income of $17,000 a year.  Most young people in Tyler’s situation opt to take their chances and just go without health care and insurance.  Tyler on the other hand does not see his health and financial security as a viable gambling chip.  This reality recently became apparent to him when he witnessed an uninsured friend have an emergency appendectomy leaving him with an $8000 bill, or otherwise stated, a half year’s salary for Tyler!

Where does someone like Tyler go?  He describes himself as being in a losing situation, and he appears to be right.  Explore his options:  Medicaid-no, he’s not poor enough.  Medicare-no, he’s not old enough.  CHIP- no, he’s too old.   VA-no, he’s not a veteran, Pennsylvania’s Adult Basic Program-no, the program was recently eliminated.  Employer provided care-no, they do not offer insurance and they are not obligated to.  The walls of our dysfunctional health insurance system have closed in on Tyler and left him trapped.  As our youth run into one roadblock after another, it makes me question how much we value our future.  Of those that are uninsured, 40% are between the ages of 18-34.[i]  How can we expect our future innovators, entrepreneurs and leaders to grow our economy and lead us into the 21^st century when we give them no viable options for meeting their most basic needs?  Where is our investment in the future?

The Patient Protection and Affordable Care Act will now break down the roadblocks our dysfunctional health insurance market has created for our youth.  For many young people, they have the option of staying on their parent’shealth insurance until they are 26.  Unfortunately, for Tyler, this is not an option because his parents are also uninsured.  Thankfully there are still other alternatives for people like Tyler that do not get employer provided health care.  In 2014, Tyler will have access to the individual exchanges, a marketplace where individuals will pool together in order to purchase insurance and lower the costs.  Additionally, because of Tyler’s income, he will qualify for a premiumtax credit that will ensure that his monthly premiums will not exceed roughly 4% of his income.  In 2014, it will also be harder for employers like Tyler’s to get away with not providing health care because there will be a $2000 fine if they do not provide health care and their employee’s receive subsidies in order to purchase on the exchange.  Tyler can also expect to enjoy the other standard benefits guaranteed by the Patient Protection and Affordable Care Act such as preventivecare, medical loss ratio, basic patient protections and ratereview.

Tyler’s optimism refused to be weighed down by the gravity of his current situation because he too was looking into the future.  As he hurried back to work for the anxious lunch crowd, he knew that there was hope in sight for his generation.  The many roadblocks he had encountered over the past 4 years were beginning to crumble and he and his peers would now have the tools to drive us down that road.

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[i] Source:  KCMU/Urban Institute Analysis of 2009

Laura and Michael's Story

Laura and Michael’s Story

The hand of nature’s perfect craftsmanship is apparent as Pennsylvania’s northeast mountain region delicately evolves into the pristine and fertile agricultural fields of the Lebanon Valley.  The tranquility of a late July day in Lebanon County is only disturbed when the gentle summer breeze rustles the fields of soybeans, corn stalks and barley.   The subtle voices of loafing cattle transcend the stillness of a region that prides itself in its infamous dairy industry.  Amish buggies and Mennonite farms, a common presence in this region perpetuates the sense of serenity.  These “plain people” represent the Germanic traditions embedded in the work ethic that founded this Pennsylvania Deutch region.  Generations have tilled this fertile soil which today gives rise to the occasional modern subdivision-a constant reminder that the inevitable hands of father time can even touch a region so rooted in tradition. 

Carefully nestled into this pristine farming region, is the historic town of Annville, where the voices of its ancestors can still be heard in the well preserved architecture of the old homes.  Maintaining the integrity of the ancestors is Michael, a carpenter who restores the old houses as well as builds structures for the future.  Alongside his wife, Laura, they have built a carpentry business and are an inspiration for the spirit of “rugged individualism” that has built Lebanon County and the United States. 

The traditional spirit of independent determination has been challenged by the backdrop of our modern health insurance reality.  Michael and Laura’s independent business is easily constrained by premiums that equal $6200 a year with a $2400 deductible.  Laura often refers to their health insurance policy as “homeowners insurance”.  As she explains with a subtle cynicism, “It basically means that if one of us gets really sick, all our policy is good for is making sure we don’t have to sell our house and cash in our retirement in order to pay medical bills.”  As Laura rubs her temperamental knee, she explains a common reality.  It costs their family over $8600 a year just to access the system.  After what Laura refers to as her annual “dues”, they still don’t get total coverage.  Even annual physicals are still only partially covered.  At the Age of 52, Laura should be having annual cancer screenings such as a mammogram and a colonoscopy.  However, even after paying their annual “dues”, these procedures are only partially covered.  The reality of their situation is apparent in the fact that they avoid seeking medical attention for some conditions that may (or may not) be treated.   After all, with a health policy like the one they carry, the only thing guaranteed by a visit to the doctor is a large bill, but not necessarily a cure.  Many times the gamble isn’t worth it. 

Fortunately there is hope in sight for Michael and Laura, individuals who embody the independent American spirit.  When the Patient Protection and Affordable Care Act (PPACA) is implemented, small business owners like Michael and Laura will be eligible to purchase insurance on the smallbusiness exchange (SHOP).  Since they will be pooled together with other small business owners, their costs will decrease.  Their income also qualifies them for a premium credit in order to buy insurance in the exchange which will limit the cost of their premiums to $1280-$2016 a year.  Additionally, as of 2010, they are able to access preventive care without a worrisome debt.  Basic research proven prevention practices such as cancer screenings are now covered under the PPACA.  After years of living with the suffocating constraints of unmanageable premiums and deductibles, Laura and Michael can now breathe easier knowing that there is now a MedicalLoss Ratio.  In other words, 80-85% of these dollars will now be required to be spent on actual care and not administrative costs.  Like all Americans, basic patientprotections and rate review will also apply to them.

With each tap of the hammer Michael maintains the traditions of the ancestors that used to occupy the historic homes of Lebanon County.  Their whispers of gratitude transcend the grind of the saw.  Because of the PPACA, Michael and Laura are able to run a business that preserves their heritage while adapting to the modern world that never ceases to progress into the future.

Susan's Story

Northeast Pennsylvania.  Any traveler who explores down these windy mountainous roads can learn its history merely from the road signs directing you to nearby counties and towns.  Carbon County, Lock Haven, Minersville, Carbondale: a testament to a time when coal was king.  If the asphalt of the downtown business district of my first Pennsylvania stop could speak, it would tell you a tale of classic Pennsylvania Americana.  A coffee shop, a small eatery and a tuxedo rental shop occupy some of the windowed storefronts that are frequented by its loyal patrons, but many storefronts remain vacant.  The strip malls on the outskirts of town have been a temptation for businesses and patrons alike over the past couple decades.  The force of our ever-changing global economy even permeates a town that represents the pillar of American entrepreneurship and stability.

During the spring prom season and the summer wedding months, the tuxedo rental shop is alive with the starry-eyed teenagers and brides preparing for our culture’s joyous rites of passage.  Behind the counter stands Susan, a middle-aged lifelong northeast Pennsylvania resident and owner of the shop since 1986.  Susan is home grown.  She is a graduate of the local high school and like many women of her “baby boom” generation, received a business certificate from an area business school.  She spent 20 years employed in the business office of the local newspaper while working alongside her husband growing their shop on “Main Street”.  Following the purchase of the store in 1986, Susan and her husband have raised 2 children in their northeast Pennsylvania town and are living testaments to the perseverance of the American entrepreneurial spirit that has built small towns like this all over the United States.  They are illustrations of dedication that has given back to their community when others left.

Loyalty to the community they love has not come without its costs.  Keeping a small business has always meant a constant battle for health insurance and access to health care.  While the children had the security of CHIP, Susan and her husband purchased private insurance through Blue Cross.  This insurance cost $600 a month, a sizable portion of their take-home pay from a business that only yields roughly $30,000 a year.  By 2005, they could no longer afford spending almost 25% of their income on health insurance.  Fortunately they qualified for the state Adult Basic program which only cost them $36 a month.  Unfortunately the program was discontinued in February 2011.   Susan was now part of the 47 million Americans (16% of the population) that are uninsured[i].  The dismal reality became worse when they tried returning to the private insurance market only to find it would now cost $785 a month or 30% of their take-home pay; a financial impossibility. 

Susan and her family stood with one foot on each side of the fault line of our health insurance system.  As each plate slowly slid farther from the other they plummeted into the merciless abyss that lies below the crack in the system.   Lying at the bottom of this unforgiving pit, Susan felt abandoned by society.  A sense of solitude would have been tolerable if it weren’t for the laundry list of health issues she encountered over the years.  There was the lung disease diagnosed in 2005 and the vascular condition that resulted in chronic pain in her knee and wrists.  The thyroid condition that has left her with double vision and the perpetual feeling that sand is in her eyes served as the physical reminder of her uncertain state of health. 

Through the hazy and distorted visions Susan sees out her untreated eyes, there is a light.  Because of the Patient Protection and Affordable Care Act (PPACA) there is hope for Susan.  In 2014 a new market place called SHOP(Small Business Exchanges) will be set up.  A small business, like Susan's, will also be eligible for a small business tax credit.  Finally Susan can crawl out of her abyss of solitude she has endured in the crack of the system and unite with other small business owners like her in order to lower her costs.  Now insurance companies will have to compete for their business.   Susan also looks forward to knowing that she qualifies for premium credits and will ensure that her premiums will be capped at 4% of her income.  Gone are the days when 25% of her income went to health insurance and the days have arrived when this can now be reinvested into the business.  Finally, insurance companies will be held accountable to rate review instead of arbitrarily increasing premiums every year.  They will also need to adhere to the medical-loss ratio.  Susan has added security in knowing that the basic patient protections will also apply to her.

As I concluded my conversation with Susan, the humidity of the July day gave way to the choir of crickets and cicada bugs singing their celebratory tune in a rhythmic pattern.  Maybe they were singing because the fault line that Susan battled would finally be sealed.  Or maybe they were singing because Susan was now returning to the tuxedo shop with dignity and fulfill the American dream as she prepared the next bridal party for their joyous occasion.

[i]2006 Census Bureau Estimates

My Story

At the age of 27 I had a stroke.  Many would often presume that this life changing experience solely leaves one with profound insight into the fragility of our personal health.  While this goes without saying, the unexpected lesson of my journey took me into the dark, desolate and potentially perilous under-world we used to refer to as health insurance in the United States.

As a public school teacher, I had health insurance.  I soon discovered that in the current system, that was no consolation.  In the months that followed my attack I battled the demons that lurked in the shadows of insurance claims that were denied and battled the collection agencies that relentlessly stalked me for payment.  Payments could not be made from a salary that was being garnished and credit cards that were being overdrawn to pay medical bills.  In fear, I watched my financial security sift like sand between my fingers as I desperately tried to grasp tighter.  As I laid in steadfast stillness in the confining chambers of an MRI machine, my thoughts should have been focused on my health situation.  Instead, my mind was muddled with the worry and anxiety of whether or not the bill for this most-likely expensive procedure would be covered.  The voice of the customer service agent from my HMO resonated through my head, “We’ll pay to take the MRI, we just won’t pay to READ the MRI”, she said in response to a pervious procedure.
 

The desperate and tear-filled phone calls to faceless customer service agents came days after I stood in the office of the woman who ran human resources for my school district.  I watched her nervous face as she flipped the pages of her calendar and counted days.  What was she counting?  Why was she flipping through the months that had passed?   As she completed her flipping a glimpse of relief filled her eyes as she looked at me and uttered the statement, “Phew, you made it”!   What did I make?  Unaware, I found out a clause that was in my insurance plan that stated that as a new employee who had just completed graduate school and had only begun employment the previous August, I had a 6 month grace period before my insurance was active.  I made it in less than 48 hours. 

In the years that followed, I found a sense of stability but the shadows of anxiety continued to hover over me.  Everyday I am grateful for my health, but I continued to worry about what would happen if I had another incident and it was more serious.  Would my family go into financial ruin if I ended up in a long-term care facility?  After all, my policy had a $1 million lifetime cap.  Would they then have to resort to liquidating all our assets (our house, savings, retirement, college savings) in order to meet expenses after the lifetime cap was filled?  What would happen when I change jobs?  Would I be denied coverage because of this condition I now have?  I just didn’t understand it.  I did everything our culture asks of me.  I received an education, established a career that contributes to society, saved wisely and obtained health insurance.  The only thing I did wrong was get sick. 


The security of my health is now on the horizon for me.  Because of the Patient Protection and Affordable Care Act, by 2014 the demons that haunted me will now be confronted with justice when the lifetime caps that threatened me with financial ruin will be eliminated and my insurance company can no longer recind coverage when someone gets sick.  In 2011 patients can appeal when an insurance company denies their claim.  In 2014 I will have more healthcare security when I can no longer be discriminated against based on my stroke condition because it is a pre-existing conditions.  No longer will someone have to go uninsured while having a lapse ofcoverage for six months when they leave school or change jobs.  Finally, because of the Affordable Care Act, we will know that patients will be returned the power and control they lost from a corrupt system.  Insurance companies will now be held accountable to a Medical-Loss Ratio, a provision that states that they have to spend 80-85% of my premium dollars on actual care and not the administrative costs that they used to deny me coverage during those dark days when I was 27.

It’s been 10 years since my stroke incident.  Maintaining my medical condition is a natural part of my daily life.  However, like many Americans, another predictable part of my life has been watching my premium responsibilities substantially increase and consume more of my take-home pay.   A hidden tax per se.  In 2014 my "hidden tax" will be lowered and I’ll be able to take home more of my pay because the PPACA states that insurance companies are subject to rate review.  In other words, my premiums cannot increase higher than 9.5% of my income.

I'm a health educator by profession and have spent my entire career dispelling myths regarding a variety of health issues.  Recently, my greatest frustration is on how little the public really knows about the PPACA and how many false pieces of information they believe.   I often look back at my endeavor and feel a sense of guilt.  I was one of the lucky ones.  Yes, I fought many battles over denied claims and spent years paying off healthcare debt.  In the end however, I was the last drop of water that made it through the dike before the flood waters could swallow me up.  I avoided the lifetime caps and grazed the six month lapse of coverage by hours.  It was with sheer luck that I circumvented the cracks in our system.  Many others out there have not been so lucky and have fallen through those cracks. 


As an educator, I have done my share of “powerpoint presentations” filled with facts and data to drooling audiences with heads ready to fall onto the desk.  Yes, health policy is pretty boring stuff!  People however, are not boring.  It is with this inspiration that in the summer of 2011 I headed out to cross the state of Pennsylvania and find others willing to share their stories and see how the PPACA will apply to them.  Beginning today, every friday for one year I will share their stories.