Health-care reform’s have-nots: who has the right to remain without heathcare?

Health-care reform’s have-nots

U.S. Census Bureau data indicate that 7.2 million adults earning less than twice the federal poverty level – about $21,000 for an individual and $44,000 for a family of four – would make too much to qualify for the expanded Medicaid envisioned by the Senate.   People without insurance or who can’t afford their employer’s insurance, if they earn up to $43,000 individually or $88,000 as a family, would receive sliding-scale federal subsidies to help pay for private insurance, which everyone is required to buy.  Well, almost everyone.  If your premiums, even with federal assistance, equals 8% of your income, you could get a “hardship” exemption.  (The exemption is for premiums only, not for co-pays or other charges.)  Who could receive the “hardship” exemption and earn this privilege of remaining without healthcare?

Philadelphia Inquirer, January 4, 2010

Health-care have-nots

Reforms in the pipeline would leave millions of Americans in a bind, given too little government help to buy insurance.

By Rick Schmitt

Michael Rhoads seems just the sort of person who would benefit from health-care reform.

He and his wife, working parents of two children in Southwest Philadelphia, lack health insurance. They earn too much to qualify for Medicaid and too little, they say, to afford private coverage.

Congress is seeking to bridge that gap. But Rhoads says the likely cost of the solution would still be beyond his family’s budget.

“Health care for everyone – that sounds wonderful,” says Rhoads, 35, who works part time as an outreach coordinator for a community health clinic. “In reality, when it comes down to it, it is another big bill that just doesn’t fit.”

Millions of people who are among the intended beneficiaries of health-care reform may face the same dilemma. Many might have to choose between insurance and necessities like rent and food, says Richard Curtis, president of the Institute for Health Policy Solutions in Washington.

“These are not people with discretionary income,” says Curtis. “Asking them to pay any substantial share . . . I worry about that.”

To be sure, millions of vulnerable Americans will get a safety net if the legislation now headed to a House-Senate conference committee becomes law. Both chambers propose raising the income limits for Medicaid and including adults without children for the first time.

Those moves alone would add an estimated 9.5 million childless adults to the state-federal insurance program for the poor under the Senate version. But a big chunk of the uninsured population would just miss the cut.

To illustrate how health reform might affect them, Georgetown University’s Center for Children and Families assessed the prospects for several Philadelphia-area families, including the Rhoadses.

The center, a nonpartisan policy and research organization that is dedicated to improving health coverage for families, used their current earnings and insurance status. Its findings are based on the bill that passed the Senate on Christmas Eve; most political analysts consider it the likely blueprint for any final health legislation that Congress approves.

U.S. Census Bureau data indicate that 7.2 million adults earning less than twice the federal poverty level – about $21,000 for an individual and $44,000 for a family of four – would make too much to qualify for the expanded Medicaid envisioned by the Senate. People earning up to four times the poverty level – about $43,000 for an individual and $88,000 for a family of four – would receive federal subsidies, on a sliding scale based on income, to help them buy policies on a series of “exchanges.”

The exchanges – private marketplaces regulated by the government – would be set up to offer coverage to people who have no insurance or who cannot afford insurance through their workplace. Some small businesses would also be able to purchase insurance for their employees. At the core of the overhaul is a requirement that most individuals and families obtain health insurance or else risk a federal fine. Under the Senate bill, that penalty would reach as much as $750 per person or 2 percent of household income, whichever is higher, although there would be a “hardship” exemption in cases where the cost of premiums totaled 8 percent or more of income.

The families examined for this article most likely would qualify for the exemption – and would be left in the same place they are now: without health insurance.

Rhoads and his wife have spent most of their adult lives without health insurance. Over the years, she has large unpaid emergency room bills. Both of them go to the doctor only when they are so sick that they cannot work.

The couple’s two daughters, 13 and 15, both receive free care under the Children’s Health Insurance Program, a state-federal initiative for low-income families that would continue to operate under the Senate (but not the House) legislation.

Their combined household income is about $40,000 a year – not enough, Rhoads says, to pay $350 a month for the cheapest insurance available from the nursing home where his wife works as a certified aide.

The cost is high enough to make them eligible for a subsidy to buy insurance through the new exchanges. According to the Georgetown University center’s analysis, however, under the Senate bill they would also be expected to contribute about $200 a month, 5.8 percent of their income, toward the cost of the premiums. Copays and deductibles would likely add several hundred dollars more a year.

Rhoads says they still couldn’t afford health insurance.

Danielle Simmons, 23, a medical assistant and student at Community College of Philadelphia, is also uninsured. And she could be in more perilous shape.

Under the Senate bill, she would have to pay 8.1 percent of her income, or about $246 a month, for her share of premiums on a government-subsidized insurance policy.

Simmons, a single parent, says she already has more bills than she can handle. Like the Rhoads children, her 5-year-old daughter qualifies for CHIP. But she pays $840 a month for a Christian preschool. The heating oil bill for the house she shares with her sister is expected to hit $4,000 this winter. She still has $15,000 in unpaid student loans.

Adding another expense, even health insurance, “would not be on my radar,” she says. So she tries to keep on top of her health using her own medical knowledge and self-discipline.

Simmons has lupus, an auto-immune disorder. She keeps the condition under control, she says, through careful diet, zealous attention to hygiene, and prayer.

The potential gaps in coverage underscore how budget considerations have been driving the debate in Washington. While they want to cover as many people as possible, lawmakers are also trying to keep the tab below $900 billion over a decade, a marker set by President Obama.

The Senate bill would cost less – and be less generous – than the House’s on several measures, including subsidies. A study by the Urban Institute last month found that the poorest and sickest families qualifying for subsidies under the Senate bill could end up paying as much as 13.4 percent of their income on health care, nearly double the 7.6 percent under the House version.

To cushion the blow, the Senate would help states set up basic health plans for low-income individuals and families who don’t qualify for expanded Medicaid. How well they might work is far from clear. A comparable program already in place in Pennsylvania, known as adultBasic, has seven times more applicants than it can enroll because of shortfalls related to the state budget crisis.

Mahawah Sillah, who has diabetes and hypertension, is one of those waiting for help. She earns about $41,000 a year as a diet technician at a hospital and has three children. Her income, about 185 percent of the poverty level, makes her eligible for the basic health assistance from the state, but she is stuck in the backlog. (Her children are covered by CHIP.)

Sillah, who lives in Yeadon, also appears unlikely to gain much from the pending federal legislation. She makes too much to qualify for the planned Medicaid expansion. With monthly mortgage and child-care payments, and thousands in legal bills for her husband’s immigration problems, she says she can’t afford the insurance offered by her employer.

The Senate bill would require her employer to kick in some money to help her buy insurance. But she would still face about $200 a month in premiums – double what she says she can handle.

A few months ago, Sillah, 40, landed in the emergency room after a fall that was related to her high blood pressure. The bill, which she says she cannot pay, was $20,000. Collection agencies have started phoning.

Sillah’s prescription for dealing with her own personal health-care crisis: “I screen my calls.”

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