Fiona O’Connell is familiar with the working person’s health care nightmare — the one where you get too sick to work, and then you lose your job, and then you have no insurance to pay for the treatment you need.
O’Connell lived that nightmare, and she’s still bitter and angry.
But now she can talk about it in the past tense. As of Jan. 1, the cancer survivor has medical insurance under the Affordable Care Act. One of the central provisions of the law is that no one can be denied coverage or charged higher premiums because of a pre-existing condition. And there are no annual or lifetime caps on insurance coverage.
“Until this year, if you had cancer or a history of cancer, you were out of luck,” said Karen Pollitz of the Kaiser Family Foundation (KHN is an editorially independent program of the foundation) , which researches health care and health care policy. “That’s different now. It’s a historic change.”
It’s also a change that can make the difference between life and death. According to the Barack Obama administration, Americans who are uninsured and diagnosed with cancer are 60 percent more likely to die of that cancer than those who have insurance.
But Pollitz and other experts say the federal health overhaul, as important as it is, does not solve all the problems facing such patients. A Kaiser tracking poll found that, despite government subsidies, some people still can’t afford their premiums or find the out-of-pocket costs (deductibles, copays and coinsurance) too burdensome.
Such expenses are capped at $6,350 a year for an individual and $12,700 for a family, but “that’s more than a lot of people can afford,” Pollitz said.
In addition, because the sign-up process was new and complicated, some patients are finding that doctors they thought were covered by their new insurance plans are outside their network, which means they have to pay a higher share of the cost of their care if they choose to stay with previous providers.
While the stakes are especially high for cancer patients, their experiences also reflect the broader realities for consumers as they start to benefit from the federal health overhaul while confronting its complexities.
To O’Connell and several other cancer patients interviewed, however, any drawbacks are a small price to pay for access to good medical care.
O’Connell, 54, had worked as a property manager for a company whose benefits included employee medical insurance. But in 2007 she was diagnosed with breast cancer and proceeded to go through months of surgery, radiation and chemotherapy.
After stints on short-term disability and unpaid leave, O’Connell offered to come back part time but was turned down, she said. Eventually she lost her job, and her cancer meant she was uninsurable in the private market after her COBRA benefits ran out.
With help from a relative who works in the insurance industry, O’Connell found coverage through the state’s former high-risk pool, known as ICHIP. It was expensive — $900 to $1,200 a month, she said — but she felt grateful to have it.
Now O’Connell, who lives in Burr Ridge, Ill., has a Blue Cross Blue Shield policy for which she pays $332.95 a month, including dental coverage. (That includes an income-related federal subsidy of $354.) Her annual deductible is $1,000 for network providers and $2,000 for out-of-network providers. “But most of my doctors were in the plan I chose,” she said, “so I have no issues there.”
Kathy Kinsella, 62, of Hinsdale, Ill., is also happy with her new coverage. Like O’Connell, Kinsella has a history of breast cancer as well as other illnesses and injuries that caused her to rack up hundreds of thousands of dollars in medical bills. Even though she had insurance through ICHIP, “I worried I was about to reach my lifetime cap,” she said.
Before the Affordable Care Act, insurance companies typically cut off coverage at $1 million. According to the Obama administration, more than 60 percent of bankruptcies in the U.S. are medically related, and three-quarters of those who go bankrupt have health insurance.
Kinsella now pays $274.29 a month — after a $386 subsidy — for a gold-level policy with a $250 annual deductible and an out-of-pocket cap of $2,000 that allows her to continue receiving care both locally and at the Mayo Clinic in Rochester, Minn.
But another breast cancer survivor discovered her new policy does not cover doctors she thought were included.
Rose, a 64-year-old Chicagoan who asked that her full name not be used, was diagnosed three years ago and treated at Rush University Medical Center in Chicago. When it came time to sign up for health insurance under the Affordable Care Act last fall, she chose a gold “choice” PPO option and was assured by the navigator who helped her apply that all her doctors were in the network.
“But when I registered for my annual mammogram and checkup with the breast surgeon last week, they told me it would only be covered out-of-network,” Rose said, “which means I’ll have to pay 40 percent of the cost and meet a higher deductible.”
(Mammograms are covered under the law with no cost-sharing when used as a screening tool, but for patients with a history of cancer such tests are considered diagnostic procedures, not preventive services.)
Mary Ann Schultz, a spokeswoman for Blue Cross and Blue Shield of Illinois, said consumers should not assume all providers at a given hospital are covered just because some are. “Each doctor signs their own contract with an insurer,” Schultz said. “Even doctors within the same practice may not be in the same network.”
There are “many ways to check to see if a provider is in network — phone, Internet, mobile app,” Schultz said.
Rose said she logged more than 20 hours on hold with the insurer’s customer service number but never got through. She also submitted three email requests without receiving a reply, she said.
Her example highlights the complexity of choosing an insurance plan. Researchers at Virginia Commonwealth University reported this year that about 50 percent of consumers buying insurance on mock exchanges picked plans that did not offer adequate coverage for their health status.
Medical professionals didn’t do much better. In another experiment, the researchers asked 70 residents and medical students to choose the best plan for a hypothetical patient. Two-thirds of them did OK when asked to pick among three plans, but only one-third chose the right policy when nine were offered. In real life, a typical patient shopping on HealthCare.gov — the federal website that hosts the insurance exchange for Illinois and 35 other states — may find three dozen plans from which to choose.
Advocates say consumers should look beyond monthly premiums to figure out their overall expenses, taking deductibles and other forms of cost-sharing into account. The American Cancer Society’s Cancer Action Network and other advocacy groups generally recommend that cancer patients choose gold or platinum policies, which have higher premiums but lower out-of-pocket caps.
“People are going to learn,” said Laura Phelan, policy director for Get Covered Illinois, the state agency charged with helping residents find insurance. “This is Year 1. Next year, when they buy their plans, they’ll know what to look for.”
Another complicating factor for cancer patients is the cost of prescription medications, which can vary widely by state and plan.
A study by the Leukemia and Lymphoma Society found that some plans in Florida and Texas had 50 percent coinsurance rates for specialty drugs, meaning consumers could be on the hook for half the cost of medications that sometimes run thousands of dollars per dose.
In California, the highest coinsurance rate was 30 percent, and in New York copays were typically $70 per drug for a month’s supply. The study did not look at drug costs in Illinois, but the summary of benefits of Blue Cross and Blue Shield of Illinois’ gold PPO plans shows that the copay for a specialty drug is $150 a month.
When the Cancer Action Network examined drug coverage in five states and the District of Columbia, it found that information on cancer drugs — especially intravenous chemotherapy agents — was not easy to come by. The researchers concluded: “We found … that cancer patients would face a difficult, and in some cases impossible, task in making apples-to-apples comparisons of health plans based on drug coverage.”
Dr. William Kamanda, a hematologist and oncologist in northern Indiana, said he has had to change some patients’ medications because the ones they were taking were not on their new plan’s list of covered drugs — called formularies — or were assigned to a high tier where the patient’s portion of the cost was onerous.
“You don’t always know which drugs are on their formulary, and that can be a headache for a busy practice with limited staff,” said Kamanda. “Most of the time we try to use generics instead of brand-name drugs to reduce costs. But even with generics, (insurance companies) will choose which ones they will cover.”
Kirsten Sloan, senior policy director for the Cancer Action Network, noted that insurance companies always have been able to limit formularies. “Tiering and high cost-sharing for prescriptions are issues that predate the ACA,” she said.
Similarly, insurance companies have long kept costs down by restricting patients to narrow networks of providers. But some advocates fear this trend may be exacerbated under the new health law.
“We don’t have good data yet on how often cancer centers are included” in insurance plans, said Pollitz. “Sometimes these specialty hospitals have high prices and are not open to negotiating discounts with insurers. It’s not clear who’s going to blink first. Are the cancer centers going to worry that insurance companies can live without them, or are the insurers going to pay their prices?”
Despite these issues, the Virginia Commonwealth researchers concluded that, overall, the health care overhaul will have a positive impact on cancer patients by allowing for increased preventive care and the option to take time off work to focus on treatment without fear of losing their health insurance.
Pollitz agreed. “The only thing that can make cancer worse,” she said, “is to not have a way to pay for the care you need.”