The Healthcare Serf: Linda's Story

This is part of a 5 part series called "Faces from the Frontline".  Join "Health on the Horizon" on Facebook and Twitter.  

Linda:  Lancaster County, PA

It was a Friday in mid April when I met Linda in a Central Pennsylvania coffee shop.  It was the end of a good week.  On Monday Linda had received her certification as a licensed massage therapist and hours before our meeting, she received a position at a facility in Leola.  An aura of relief surrounded her.  It had been a long year.

With a Master’s Degree in public administration, Linda spent 17 years as a research project manager.  Her most recent job was at a large Central Pennsylvania Facility.  While her career had been a fulfilling one, the stress of this demanding profession began to take a toll on her health and wellbeing and it was time for a change.  After years of examining the practice of massage therapy, she saw this as her new calling.

At the age of 52, redefining yourself can be a frightening thing.  Leaving the security of a stable career that offers a good salary with benefits and going out on your own can often feel like walking a tightrope without a safety net.  Like Linda, many people can relate to reaching the point in their lives where it is time to change course and embrace independence, freedom and individualism.  After all, aren’t those the core principle’s America was founded on?

Not with our current healthcare system.

In 2008, nearly a quarter (23%) of Americans reported taking a job or staying at a job they no longer wanted to be at solely for healthcare benefits, according to the Kaiser Family Foundation.  Linda was one of them.  For months, Linda tried to balance school with her full-time job primarily to keep her healthcare benefits.  She explains that living without her salary for a time did not scare her, but the thought of not having health benefits was frightening.  She had never been without health insurance and she only stayed at her job because of them- she was a “serf” to her healthcare.

It was a grueling choice for her, but one that made her engage in deep self reflection to explore the priorities in life:  personal happiness and living a life with meaning.  Ultimately, Linda had to leave her job when the courses necessary for completing her degree were only offered during the day.  Unable to pay for a policy on the expensive individual market, she joined the ranks of the uninsured.  A recent study by the Commonwealth Fund found that individuals, like Linda, seeking policies on the individual market found it unaffordable and 45% went without a policy.  While she wasn’t alone, she felt vulnerable and alone.  Linda recalls harboring a sense of shame for not having health insurance, as if society viewed her as somehow inferior.  However, the irony, doesn’t our society celebrate personal independence?  

The United States is the only country in the industrialized world where individuals are left vulnerable when they leave their employer-based healthcare.  This makes me wonder that in a country that celebrates the ideas of “freedom” and “individualism”, how truly free are we when we are strapped to our employers in order to meet our most basic human need? 

In 2014, the Patient Protection and Affordable Care Act calls on states to set up individual exchanges/marketplaces for people such as Linda.  These exchanges are designed for uninsured people (people who don’t get insurance through their employer, people who are in between jobs or lost a job) to have a place to go for affordable healthcare.   The individual exchanges/marketplace will consist of a wide variety of private insurance plans where consumers “shop” on the internet.  By pooling many consumers together, it will be more affordable than going alone on the individual market.  Premium tax credits are also available for individuals up to 400% of poverty level.

The Ritter Family's Story

This is the first in a new series called "Faces from the Frontline".  Join "Health on the Horizon" on Facebook and Twitter.

The Ritter Family:  Marlboro County, PA

Motherhood prepared Stacie Ritter for more than any woman could ever imagine.  When I met Stacie Ritter speaking to a sizable crowd on the steps of the Supreme Court on March 27, 2012 advocating for the PPACA, I met a mother on a mission.  I soon discovered that the advocacy training of this mother of four was unknowingly thrust upon her 10 years prior when her twin daughters, Hanna and Madeline, were diagnosed with cancer at the age of 4.  Now age 14, Hanna and Madeline looked with admiration at their mother that morning.  It had been a long road to get to this point.

In 2002, Stacie and Ben were embracing the American Dream.  Married for a few years, they owned a home in Marlboro County and were beginning their family with a set of twin girls, a toddler and another baby on the way.  No parent can imagine the fear and horror of being on the receiving end of a doctor’s diagnosis when you are told your children have cancer.  Stacie and Ben lived that nightmare-bone marrow transplants, chemotherapy and radiation.  Unbeknownst to them at the time, this nightmare was a multi-part series.

Within a few months of treatment, the girls reached the lifetime caps allowed by many insurance plans.  Prepared for this possibility, they purchased secondary insurance through the State’s CHIP program.  Ben ultimately had to take an unpaid medical leave from his job in order to take care of his two sick daughters, a toddler and a pregnant wife.  In order to make sure the rest of the family was not left without health insurance, he took out a COBRA plan at the cost of almost $800 month.  With the cost of the COBRA plan, a mortgage, groceries, electricity, gas and other monthly expenses, the family went through their savings and all their assets in less than one year and ultimately filed for bankruptcy.  While Stacie and Ben were filing for bankruptcy, the health insurance industry recorded a 162% profit for the first quarter of that year (weiss).

This is the state of healthcare in America.

In fact, half of all bankruptcies in the US are triggered by costly medical expenses (Warren).  Most would presume that these individuals are uninsured, however, the reality is quite the opposite.  According to Health Affairs, 60% of those that filed for medical bankruptcy in 2005 were insured (Himmelstein).  Stacie describes their medical bankruptcy like many others that have been victims of  a broken healthcare system, “until you’ve been there, see it and feel it, people don’t understand the reality of this issue”.

Political contributions of America's Health Insurance Plans
during the healthcare reform debates

While the girls experienced a remission from their cancer, the nightmare wasn’t over.  A few years later the girls began to experience problems with their pituitary and hypothalamus from the radiation and chemotherapy treatments, which required an expensive prescription.  It was covered by the family’s insurance, but when Ben’s company switched plans they ran into problems.  Even though it was recommended by their world renowned endocrinologist, the insurance plan denied coverage.  For months, Stacie and the physicians fought for the girls.  They administered unnecessary tests requested by the insurance company and the physicians wrote 4 letters of appeal that were denied each time.  As the Ritter family and their doctor’s fought to get the girls the care they needed, the national debate to reform our health insurance system began to heat up.  In 2008, the health insurance industry spent $7,540,000 in lobbying and $617,200 in direct contributions to members of congress (opensecrets.com).

This is the state of healthcare in America.

As the years passed, the Ritter family stayed very active and involved in the National debate for access to fair and affordable healthcare.  They testified before the house steering committee for healthcare reform.  While not perfect, the passage of the PPACA in 2010 has given them some relief and offers them some basic consumer protections, protections that they did not have along their journey.  One very important protection is the elimination of the Lifetime Cap.  Additionally, because the twins now have a pre-existing condition, they are grateful that in the future they will never be able to be turned down for health insurance. Furthermore, until they are independent adults, they will be able to stay on their parent’s plan until age 26.    The family sees the medical-loss-ratio as a success for consumers like themselves because insurance companies will have to spend 85% of their premiums on care and not profits, administrative costs, advertising and lobbying.  

Even after its passage, the Ritter family continues to advocate for an issue and law that the general public has very little knowledge about.  On March 27, 2012, a full decade into this family’s battle for fairness in the health marketplace, Stacie and her family took their last stand.  On the steps of the Supreme Court they made an appeal before an army of press and spectators.  

From the beginning of time, mothers have gone to great lengths in order to provide the basic necessities for their children.  Stacie Ritter’s journey to care for her children brought her to the steps of the highest court in the free world. 

March 27, 2012
Meeting the Ritter Family in Washington DC

See a recent Video featuring the Ritter Family

¹ Weiss Ratings, December 18, 2002
² The Fragile Middle Class: Americans in Debt; by Elizabeth Warren, Harvard Law School and Smith Business Solutions
³ Himmelstein et al.  Health Affairs, 2/2005

⁴ www.opensecrets.com

So where do we go from here?: The future solvency of medicare

This is the last of a five part series on medicare.  Please join "Health on the Horizon" on Facebook.

Kaiser Family Foundation: Health Reform and Medicare’s overview of key provisions

One of the loftiest concerns looming over the health of the nation is the potential, and very real, threat of medicare insolvency.  Prior to the implementation of the PPACA, the Medicare Trust Fund A (which funds hospitalization) was due to no longer have sufficient funds to cover all patient hospital care by 2017.  Since its passage, the life of this fund has increased to 2029.  This is due to shifting the overpayments that have been made to Medicare Advantage (the private alternative) back to traditional Medicare.  While this provision in the PPACA gives us some relief in the short-term, it stands as a warning that the future of our senior populations is in dire straights if we don’t make some difficult choices.

According to Barbara Dickman, a volunteer representative for the Pennsylvania’s AARP and sat on the legislative counsel for 2 years, the 2010 Healthcare Reform law has begun to address the long-term solvency of Medicare.  However, there are many elements of the law that need to be allowed to work in order to give the program the security it needs.  She explains, “The law calls for providers to be more efficient with the money given to them from Medicare by examining how physicians get paid. Furthermore, it will set up the Independent Payment Advisory Board which will analyze the growth of national health expenditures.  This law also provides for means to target weeding out waste, fraud and abuse.”

First of all, there will be incentives for primary care services by providing a 10% bonus payment to providers if at least 60% of their medicare allowed charges in the prior period were for primary care as opposed to specialized or emergency care, which is more expensive.  More focus will be given on keeping patients well and preventing hospital readmissions where costs are higher.  To do this, a Medicare pilot program will be launched which will look at bundling payments.  In other words, physicians will be paid a set amount to treat a specific condition and not for each individual test and procedure.  Electronic medical records will play a big role by prevention of duplicated services and enhance the ability of physicians to share records and tests.

According to the Dartmouth Institute for Health Policy and Research’s infamous “Atlas Project”, 30% of Medicare dollars are wasted.  Weeding out waste and abuse is essential to lowering overall healthcare costs.  This includes money spent on such things as duplicated and unnecessary care.  The PPACA calls to develop a database to capture and share data across federal and state programs.  Funding has also been increased for anti-fraud activities and steeper penalties for those who commit fraud.    

Furthermore, another important aspect of enhancing the longevity of medicare is the medicare payroll tax on high income earners which will begin in 2013.  This will be a .9% medicare tax increase on individuals making $200,000 and couples making over $250,000.

In the end, because of the reforms put in place, the Kaiser Family Foundation projects that the growth of medicare spending on a per person basis is expected to be slower than those of private insurance plans.  For now it is a start, but now we need to ask ourselves, "Where do we go from here?"

   

Maybe those "Death Panels" weren't such a bad idea

This is the fourth piece in a five part series on Medicare.  Join "Health on the Horizon" on Facebook!

My first job out of college was in a rehabilitation hospital for people with traumatic brain injury, an experience that changed my life.  My primary placement was on the floor for people on ventilators, feeding tubes and in level I and II comas.  In the time I spent there I observed the pain and heartbreak confronted by thousands of families every day in this country, the inability to care for their loved ones because there were no advance directives, including a living will (a document indicating the type of medical treatment one desires if in a vegetative state).  I watched families unable to make healthcare decisions for their loved ones that were in vegetative states because there was no health care proxy (a legal document designating another person to make healthcare decisions if you are ever rendered incapable of making them known).  For some of these families this nightmare went on for decades.  

Soon after my experience working with these patients and their families, I made the decision to do everything in my power to never put my own loved ones through the same trauma.  I called a lawyer and completed a “health care proxy” and “a living will”.  I was in my late 20’s and the lawyer chuckled that I was not only the youngest client, but among the few he had ever issued this legal documentation to.  A sad statement, but true.  In fact, according to the University of Minnesota Center for Bioethics, less than 5% of people over age 65 have advanced directives.

When the Patient Protection and Affordable Care Act was first signed into law in March 2010, there included a provision for voluntary end of life counseling for Medicare patients.  This would have allowed Medicare patients access to completing a health care proxy and living will.  However, in January of 2011, Obama reversed course on the provision and it was removed (New York Times, January 5, 2011).  This voluntary access to end of life counseling would not only save thousands of families from the years of heartache I observed, but would also save our Medicaid and Medicare system millions of dollars by no longer performing costly medical interventions that are being done against a patient’s  will.  Estimates show that 27% of Medicare’s annual budget goes to recipients in their last year of life.   

To understand why Obama did this we need to reflect back upon those chaotic days of when we were debating health care reform.  The misinformation, political grandstanding and lobbyists in Washington were abundant.  The volume was high and the noise was loud.  The ignorant fears that labeled these advanced directives as “Death Panels” flooded the news.  The opposition was willing to say anything for political gain.  Guess what?  It worked.

While the provision made it into the original legislation, Obama removed it soon after when the noise started going up again.  He caved to the political pressure at the expense of public health.  It’s been about 15 years since my days working with coma patients and their families and I think about them often.  These family members came loyally each day for decades to support their loved ones.  In the end, they were powerless.  This heartache would have been prevented if only these patients had access to “death panels”.