As the U.S. Supreme Court weighs the constitutionality of the Patient Protection and Affordable Care Act, the Daily Sun asked area residents what it has meant for them already and could mean when fully implemented.
A couple seeks insurance coverage for maternity, and a small business gives its take on high costs.
A widow shares her story about paying for nursing home, and a patient with a serious medical problem talks about losing insurance, then regaining it.
Local health care providers are skeptical and curious: They are already seeing an impact on patients after state cuts to the existing insurance program for the poor, but they also wonder whether small federal payments for treating patients will squeeze more here out of business.
Following are their stories and others:
Stork makes U-turn
Dana Holloway, 37, and her husband want to have a second child and give their 3-year-old son a sibling.
She works two jobs; he works one, and together they saved and planned to put son Gabe into Montessori school before having another.
But when Holloway checked into insurance options, she was surprised to learn: No plan she could get will cover a healthy, routine pregnancy, estimated at about $30,000 for her because a Caesarean section is likely.
"I probably talked to about 10 different people and was told the same thing by everybody: That maternity is not an option on individual policies," she said.
A local broker at Benefit Logic said the same: Very few insurance policies cover pregnancy anymore.
"I'm definitely very frustrated and unhappy about it," Holloway said.
If the Affordable Care Act were to stand into 2014, private insurance companies would have to cover maternity, according to information out in late March from the U.S. Health and Human Services Department.
But that doesn't help Holloway right now.
Gabe's dad formerly worked for a company with health insurance when Gabe was born, but no longer.
So Holloway's family is quite the minority in one way: They buy their own insurance at more than $400 per month, because employers in the food service industry where each works do not offer it.
Fewer than 6 percent of people in the country buy their own insurance.
The policy they have would not cover a pregnancy, so the couple won't be having a baby anytime soon, they have decided, because they can't afford it.
"Either that, or we pay for the next 20 years," Holloway said.
Health problem too costly to treat
Carmen (not her real name) was insured from before she was born up until a little more than 16 years ago. That's when she was told that her adrenal glands weren't making hormones sufficiently.
That's a serious problem that can affect the immune system, and the body's ability to regulate sugar, keep the heart beating normally, or respond to stress.
She badly wants to tell policymakers: No one really knows if their health insurance works until it's tested.
"I get so irritated when I hear the politicians talking about letting the free market work. I was insured from the moment that my mother was expecting me, up to the time that I was diagnosed with a chronic illness. The free market worked when you were healthy, and when you were not healthy -- not so much," she said.
The Flagstaff woman has asked that her name be withheld to protect her privacy, in sharing candid stories about her medical history.
Carmen's premiums were once $76 per month.
After diagnosis, she eventually moved to a $10,000 deductible (that's the amount a patient must pay each year before an insurer begins picking up some of the bills).
But when her insurance premiums grew larger than her mortgage payments, she couldn't afford it anymore, so she became uninsured for 16 years.
In that time, she patched together visits to clinics, drugs from Canada and payments out-of-pocket for the doctor visits she had to have.
She once stayed awake all night after a fall, fearing she had a concussion.
"I had things occur to me that I should have gone to the ER but didn't, because I could imagine how much that would cost," she said.
She wasn't alone: Almost half of uninsured adults in the United States with chronic conditions avoided medical care or prescription drugs they needed due to cost, a 2005 study from the University of Maryland and a nonpartisan policy group found.
Another study found about one-quarter of uninsured adults had used up all or most of their savings paying medical bills in 2010.
But it was in 2010 that things changed for Carmen.
The federal government, as part of the Patient Protection and Affordable Care Act approved by Congress, opened a short-term insurance option for people with existing health problems, like cancer and heart disease.
Carmen got on that, at $280 per month, but rates for that option have been cut substantially in the past year.
Individuals must show they've been uninsured for six months or longer and that insurance companies won't sell them policies because they have a chronic health problem.
Carmen's now on Medicare, and gets medical care as needed.
"It's reassuring to know that you're able, if you need to, to go to the hospital for something," she said.
tax credits unused by small employer
Fran Algya co-owns Flagstaff Equipment, which sells items like tractors and snowblowers.
The company employs eight, and it has seen insurance costs increase between 20 percent to about 50 percent from one year to the next, Algya said.
Of eight working at the business, only three buy its insurance, which comes with premiums of about $175 per month for individuals, and $600 per month for families.
Most minor medical appointments mean paying cash up front, as the deductible is $10,000 for a family in this case.
"We pay most of our doctor bills," Algya said, because the deductible is that high.
The business might be eligible for a tax credit given to small businesses with fewer than 25 full-time employees and paying at least half the cost of their health insurance.
Algya said she hasn't been getting any tax credit to her knowledge.
Neither has any other small business in Flagstaff that he knows of, says Rodney Wilson, a certified public accountant.
"I'm not seeing anyone use it so far," he said.
The program offers a tax credit (an amount taken right off what a business owes to the Internal Revenue Service) worth 35 percent of whatever an employer contributes to an employee's premiums, with some limits.
The credits to businesses can amount to $1,600 for individuals and some $3,800 for families.
Wilson says small businesses aren't often offering insurance to employees here, because they can't afford it.
"I feel like most employers up here don't feel like they can afford to pay out that extra amount," he said.
If the Patient Protection and Affordable Care Act approved in 2010 stands, employers like Flagstaff Equipment will have the option of shopping for insurance in any of the ways they choose now, or through a state or federal exchange allowing them to compare plans and possibly receive discounts.
The Congressional Budget Office has estimated that about 3.7 million employees working at small businesses nationwide (or 7.5 percent of those uninsured in the country today) would get health insurance through one of these exchanges in 2017, if the legislation stands.
Nursing homes costly
Great-great-grandmother Lois Gass, 78, has high cholesterol, an irregular heartbeat, a breathing problem, diabetes, and relies on oxygen all the time.
She learned about all these problems about six years ago, and most all of them at the same time during a hospital stay.
Gass estimates she spent $3,130 on prescription drugs last year, and while that is substantial on her income, this isn't her big worry.
Her husband, a truck driver, suffered a brain injury and she reluctantly put him in a nursing home at his physicians' urging in 1994, where she spent $104 per day.
He had a brain injury, and was later diagnosed with five other problems, two of which affected his mind.
The bills added up to about $75,000 before he died in 1997, after they had been married 47 years.
"You try to watch everything you do. You don't spend much money," she said.
Gass pays $80 per month for long-term care insurance that would cover her own care in a retirement home or nursing home.
Health and Human Services Kathleen Sebelius shelved proposals in October 2011 to offer more long-term care for seniors, particularly those providing assistance to help them remain in their homes.
Working poor at risk
Henry and Nina Poore opened a free clinic in Flagstaff in October 2011 for people without private or government insurance. They treat kids, do minor surgeries and fix common health problems.
What he's finding in a few cases, though, is a segment of working people too affluent (minimum wage or more) to be on Arizona's Medicaid program, and too poor to afford the major help they need.
In the months he's been open, he's had a person needing an organ transplant and several people needing serious surgeries for conditions like major hernias come into his office.
"These are desperate people," he said.
He lobbies other doctors to take them at no cost.
Getting another office to take the case often requires a CT scan, at several thousands of dollars.
Not getting them surgery puts them at risk of bigger problems or emergencies down the road, such as the loss of parts of an intestine in the case of some of his hernia patients.
Previous conditions now covered
Nina Souders is a pediatrician at Flagstaff's North Country HealthCare, where she sometimes faces a dilemma: Parents begging her not to officially find any health problems in their kids, even if they know health problems are real.
One family recently told Souders they were really close to getting health insurance for their child, and a diagnosis of a health problem could get them rejected for insurance to cover treatment.
Actually, that child with a health problem would be covered under changes made in 2010 under the Patient Protection and Affordable Care Act.
Insurers cannot deny coverage to children with existing or documented health problems, the legislation states, meaning kids with a history of moderate or major diseases won't be turned down for insurance.
If the legislation stands, that provision requiring coverage of children would be extended to adults, too, in January 2014.
The biggest change for Souders, though, has been a provision allowing young adults up to age 26 to stay on their parents' policies.
"I have seen quite a number of young adults between 21 and 26 who are on their parents' policies," she said.
Delays in care mean more triage
Heather Haseman, a nurse at Native Americans for Community Action, shows a stack of charts where she's got to call an insurance company to get pre-authorization for something, like medication or CT scans.
There's about a dozen, and it's only 10 a.m. on a Monday.
She's seems to relish this job, and she knows the direct lines into insurance companies to get who and what she needs.
"I'm very much a patient advocate," she says.
Even as the U.S. Supreme Court weighs the legality of federal legislation to insure about 32 million more Americans, Arizona is doing the opposite: It is cutting medical insurance programs for people living at less than the minimum wage to save an estimated $190 million a year statewide.
Nearly one-third of this clinic's patients are on Arizona's version of Medicaid, the Arizona Health Care Cost Containment System, which cut 100,000 childless adults from its rolls this year, among other measures.
Haseman's patients have been affected by provisions that take away podiatry, add delays to eye exams for diabetics, and no longer cover bariatric surgery for patients who've documented that they've tried everything else to lose and control their weight.
"I'm doing a lot more triage on patients who've let their health fall to the wayside due to AHCCCS cuts," Haseman said.
She had a patient with diabetes come in with a hole in his foot, unknown to him because he couldn't feel much, and a twig stuck in it.
Other patients with diabetes who feared they were losing their vision had to clear extra barriers and wait a couple weeks for eye exams due to these cuts.
The economy is at the core of these problems, Haseman feels, but they're also close to home for her.
Though she works at a clinic, her family cannot afford insurance premiums of $1,000 per month for coverage, and her children are uninsured.
Less prevention taking toll
Native Americans for Community Action Inc., a local nonprofit, sees about a 50-50 mix of Native Americans and patients of other ethnicities, or 700 to 750 patients per month.
Diabetes, hypertension and cardiovascular disease are among the top complaints, though health care workers here also immunize babies and do physical exams, said business manager Marie VanWey.
Arthur Velez, of Winslow, is here on Monday to get a checkup, after being diagnosed with type II diabetes about a decade ago.
Velez, 67, is a model patient with two kinds of insurance coverage.
He walks and bikes, takes five meds in an attempt to keep cholesterol and other problems under control, and has lost a lot of weight from a one-time high when he quit smoking.
"We've always eaten healthy," Velez says as Guadalupe "Lupe" Woodson examines his feet, testing for feeling.
Velez has tried to keep cholesterol in check, but he's allergic to some medications prescribed so far.
He's married to a cancer survivor who is in good shape, and he has both Medicare and secondary insurance, meaning the couple spends an estimated $5,000 at the upper end on prescription drugs in a year.
Velez came looking for a new health care provider after spending only about two minutes with his in Winslow who "never even talked about what I had or how to take care of it."
Woodson spent three hours with him in a first appointment, explaining things and changing out ineffective medications.
Woodson sees a lot of patients with multiple chronic conditions.
Sometimes they get denied by insurance companies when Woodson prescribes them the drugs she thinks will work best.
"Part of this is genetic, and we can exercise and diet and still have bad cholesterol. We need to give these people a better class of statin that research has shown to be more effective, more powerful," Woodson said.
Woodson sees 21 to 28 patients per day.
She estimates a patient visit used to cost her $90 or $100 from scheduling to visit to follow-up, when she had a private practice.
But the insurance companies used to pay her $45 or $50 per appointment.
Woodson ultimately closed the private practice.
"The thing I would hope is that insurance companies would step up to the plate and be more accountable, without being a third-wheel between the provider and the patient," she said.
Where people get insurance
--56% through employer
--20% Medicaid/Medicare
--18.5% have no insurance
--5.5 % buy own, privately
Source: The Kaiser Commission on Medicaid and the Uninsured
Uninsured rate
Adults
--Coconino County 26%
--Nationwide : 16%
Children
--Coconino County: 11%
--Nationwide: 10%
Source: 2010 U.S. Census
Health Care Reform Implementaion Timeline
2010
- Health care bill signed into law
- Seniors spending more than $2,800 on drugs got $250 rebates from Medicare
- Young adults could stay on parents' plans until age 26
- People with chronic health problems could buy federal insurance
- Some exams (mammograms, colonoscopies) were covered with no deductible
- Removes lifetime caps on essential services (maxing out on long hospital stays)
2011
- Appeals courts ruled on multiple challenges to the law; Supreme Court next
- Costs of some prescription drugs halved for Medicare patients
- Insurance companies must spend at least 80 percent of premiums on health care
- Preventative care for Medicare patients at no cost
2012
- U.S. Supreme Court hears challenge to health care law (March 2012)
- Hospitals stop being reimbursed for preventable problems, infections (October)
- Increasing use of electronic records encouraged
2013
- Primary care physicians to get more for seeing Medicaid patients
- Additional federal insurance subsidies to states covering children
2014
- Americans required to buy insurance or pay fines (*currently at Supreme Court)
- Medicaid coverage expanded to more (*currently at Supreme Court)
- Subsidies offered to buy insurance (up to income of $88,000 for family of four)
- Insurance companies forbidden from charging more based on health, gender
Source: Wire reports, U.S. Department of Health and Human Services
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