- Last October the federal health exchanges opened allowing all Americans to purchase health insurance under rules put in place by the Affordable Care Act. Eleven months later, an uninsured Sitka woman, Sotera Perez, was getting X-rays to confirm she’d broken her ankle.
The ACA, sometimes referred to as Obamacare, was intended to make sure people like Perez – a single mother with as many jobs (two) as she has children – could get insurance. The new law had a bumpy rollout, and there were a number of problems for Americans, including people in Sitka.
In Perez’s case, it wasn’t negligence that led her to be uninsured when her ankle folded as she stepped off a stage during sound check for a Sept. 19 concert with her band. Perez’ had tried to get insurance during last year’s rollout but her efforts did not bear fruit.
“I had budgeted for (insurance) and sort of shopped around and knew what it was going to cost me,” Perez said. “Yeah, it’s as much as my monthly utilities bill, but I figured it would be worth that price if it were offered to me.”
Perez said she was actually looking forward to purchasing health insurance when the ACA went into effect last Oct. 1. By the time she finally navigated the process, she was informed that she could not get health care through the federal exchange because she qualified for Medicaid through the State of Alaska.
“The result that I got was that I supposedly, according to the website, was eligible for Alaska Medicaid,” she said, “and healthcare.gov won’t offer you any other choices if you are eligible for any other governmental programs.”
In an effort to get health insurance to those who couldn’t get it through their employers, such as independent fishermen, the ACA set up exchanges in which Americans could buy health care through private companies with government subsidies depending on income. The law also expanded Medicaid to include more low-income adults who couldn’t afford health insurance on the exchanges.
A ruling by the U.S. Supreme Court in June of 2012 determined that the federal government could not force states to expand Medicaid, leaving it up to states to decide. Gov. Sean Parnell chose not to expand Medicaid for Alaska, citing the cost. The federal government had agreed to pay states the cost of Medicaid expansion through 2016, with a goal to scale back to 90 percent federal funding by 2020. Of the 23 states that decided not to expand Medicaid, 22 have Republican governors.
Perez’s Medicaid application to the state was never returned, so Perez continued working 50 hours a week with no health insurance. Months later she missed her step while walking off a stage.
“I have what’s called a trimalleolar fracture in my ankle. There are three bones in my ankle and I broke all three of them,” Perez said.
Before the accident Perez was pretty sure she was in the so-called Medicaid gap: people who can’t afford insurance through the exchanges, are directed to their state Medicaid program. But if your state hasn’t expanded Medicaid then healthcare.gov informs you:
“If you live in a state that hasn’t expanded its Medicaid program and you have limited income, you may not have many options for health coverage.”
After breaking her ankle Perez applied for Medicaid again in hopes that things would go differently on the second try. Even before her Oct. 1 surgery date the medical bills were coming in.
“I was terrified. I got the first round of bills in the mail the first day I submitted my (Medicaid) application. I mean, I thought I was having a heart attack for a second,” Perez said.
The ambulance ride cost her over $6,000. The cost of a day in surgery would be north of $30,000.
“Then you’re looking at twice my annual income,” Perez said.
The anticipation of surgery alone is enough to elevate your heart rate and blood pressure. That was true of Perez, but while she was on her way to the hospital for the operation she got a phone call that had the opposite effect – a call that took tens of thousands of things off her mind.
“In Juneau, I literally got the call that my Medicaid had been approved as I was pulling in to do my pre-op to go to surgery,” she said.
Perez found she was qualified for Medicaid after all, in large part because she has two dependent children.
Three weeks later she’s on the mend and facing a number of hurdles, but a mountain of medical bills is not among them. She considers herself lucky because she sees how close she was to being completely out in the cold.
“If you do not have dependent children and you are a single person, you will not qualify for Medicaid,” she said.
Perez said she doesn’t need to look far to answer the “what if” question.
“Let me tell you a story: I have a coworker who is my age – late 30s – and he has had a rotator cuff injury in his shoulder, which has slowly been getting worse the last couple of months. It basically renders him unable to perform his job effectively. When he applied for Medicaid he was turned down out-of-hand.
“He doesn’t make any more money than I do. As a matter of fact he might even make a little bit less. As a matter of fact, I have two jobs, he only has one and he can’t afford the physical therapy that he needs and his medical bills are stacking up. He’s already in his late 30s. He’s going to be in pain the rest of his life. Because it’s not a life-threatening injury, no one will do anything about it,” Perez said.
Perez said the time she spent thinking she was uninsured sharpened her perception of how dangerous health emergencies can be for people like her coworker who don’t have insurance.
“Maybe he could apply to a community hospital that has charity care but otherwise he’s stuck with this lifelong injury that he has no recourse for,” Perez said. “He doesn’t have anything. He doesn’t have insurance and he’s not qualified for government health care so, you know, where’s he at?”
Parnell continues to refuse to accept the federal funds to expand Medicaid. His opponent in this November’s election, Bill Walker, has publicly supported the Medicaid expansion. A State of Alaska study reported that 10,000 to 12,000 people are in the Medicaid gap. An outside study by the Kaiser Foundation estimates the number at around 26,000.
Andrea Thomas, the outreach and enrollment manager at SEARHC, has been helping individuals navigate the new Affordable Care Act. She said this year single people making between $14,350 and $57,400 qualify for the health insurance exchanges.
“Everybody that falls below that $14,350 is not eligible to get any assistance with paying for health care,” she said.
Next year the numbers move up slightly, as the range is based on the official federal poverty line for the state as well as family size. Sitkan Phyllis Hackett and her husband qualify as those who can’t get their insurance through an employer but who also have an income that exceeds the cap for government aid. That means they can buy insurance through the exchanges but they can’t get government subsidies for it.
New insurance through the exchanges will be more expensive than the old policies the Hacketts had.
Hackett said her old insurance was cheaper because it was not comprehensive and dealt more with emergency-type care. Those policies were made illegal by the ACA. New insurance through the exchanges would be superior coverage, but the cost higher.
“After the Affordable Care Act, we’ll have more coverage, which is fine, but our payments for us will go to $1,475 a month from $820 a month,” she said. “We’ll have more things covered, which will be helpful if we need them, but we’re going to pay dearly.”
Right now Hackett hasn’t felt much of the effect because the cancellation of the old policies was delayed, similar to other implementations of the law.
When the time does come, however, Hackett said, she and her husband may choose to pay the tax penalty rather than pay for new health insurance. She said she and her husband are healthy and don’t feel the need to buy coverage they won’t use. They may also consider working less to fall into the income level where they would get assistance. “We’re not too far past it,” she said.
Despite all that, Hackett is a fan of the Affordable Care Act.
“I’m still thrilled with it because I think it’s been an age-long problem for this country,” she said.
“It took something as drastic as this to get people looking at it … at least it’s a work in progress, which is better than what we had before.”
People making too little money struggle to find insurance while people making too much are struggling to pay for it. But for Davey Lubin, who falls within the income range in which health care becomes truly affordable, the new system is “the best thing to happen to our family since king salmon.”
Lubin commercially fished for ten years and now has a one-man ocean tour and water taxi business. He said buying insurance independently prior to the Affordable Care Act was a struggle.
“As self-employed people, we were extorted for years by the insurance companies and the system in general,” Lubin said. “We were up to $20,000 a year for a family of four for the privilege to pay another $12,000 a year out of pocket.”
Not only did Lubin’s rates go down but his family’s insurance coverage went up. His family isn’t paying out-of-pocket for doctor’s visits or having to fight for every claim.
“We haven’t had to do endless battle with every expense. Anything was almost always denied,” he said. “It was because it was just us against the monster.”
Lubin’s wife, Lisa Busch, said the family’s financial narrative changed entirely after they got insurance through the exchange.
“We were at the point where we were deciding, do we save for college or do we have health care. Because we felt like we didn’t get anything for it,” she said.
Lubin said he’s not surprised that it’s tough for some to understand how difficult the health care landscape was for self-employed people.
“We would tell our friends who were doctors how much we paid and they were just shocked,” he said. “If the medical professionals didn’t realize what the score was, then who would know?”
The Affordable Care Act continues to be a big issue both at the state and national level. The U.S. House of Representatives has voted over 50 times to repeal the ACA though the bill could not pass through the Democratic Senate. Republican Senate candidate Dan Sullivan has publicly advocated to repeal the legislation and replace it with something else, though he hasn’t specifically said what. Sullivan has been openly critical of his opponent, incumbent Democratic Sen. Mark Begich, for supporting the law.
Lubin said he’s not charmed by those who want to get rid of the Affordable Health Care Act.
“I think what needs to happen is the politicians, Congress, should have to use it and go through the same agonies that your basic self-employed individual has to go through.”
People who haven’t bought insurance yet but would like to will have an easier time of it this year, said Thomas. Last year’s healthcare.gov rollout was widely criticized for the software glitches in the system. Thomas said those looking to sign up this year will have far fewer problems.
“They’ve really made a lot of changes to the website and they’ve been rolling it out. It is quite a bit more streamlined and I think people will have a much easier time,” Thomas said.
As the end of the year approaches, people without insurance need to sign up or file for an exemption if they are to escape tax penalties, Thomas said. There are a number of important things to stay current on. Thomas suggested people be mindful of:
– policy changes based on increased or decreased household income.
– changes to family income related to the high Permanent Fund Dividend that residents received this year.
– tax exemptions that may be available for the uninsured. Some of those exemptions can be claimed at the time of filing and some can be claimed ahead of time. There are exemptions for those who fall into the Medicaid gap.
– anyone who has lost insurance can get insurance through the exchanges without waiting for the open enrollment season.
The tax penalty, Thomas said, will be either $95 or 1 percent of a person’s annual salary. There are additional fees if a person’s income goes up and that person doesn’t record the change on their insurance. Those changes can be made through healthcare.gov or by calling 1-800-318-2596. That’s also where people who don’t have insurance can go to get coverage before the start of the new year.
Thomas said she’s available to help anyone who needs it. She can be reached at 966-8883. Thomas added that health care providers in general are very open to helping people through the process.
Perez said that was certainly the case when she was dealing with the paperwork related to her ankle, which is now on the mend thanks to a plate and some screws. Medicaid can cover bills retroactively, and Perez said the hospitals and clinics went back through her old bills and created new invoices to reflect the Medicaid coverage. In fact, she said, she was being prepped for surgery at the same time the billing department was prepping her Medicaid for its first claim.
She told them her Medicaid had gone through, and the hospital billing department went into action.
“The billing department called for me and got my number, which I didn’t have yet, and got the ball rolling for me,” she said. “I think people are actually really willing to work with these governmental services because I don’t think anyone that goes into health care actually is in it to get rich.”
Perez still has a number of needs Medicaid isn’t covering, and challenges to sort out, but yet feels lucky.
“I’m lucky in that I have a little bit of savings and was able to put a little bit of money away. I’m lucky that we live in Alaska and that this injury happened at the time that Permanent Fund Dividends became available and that they were so large this year,” she said.
She still has rent to pay, kids to care for and lights to keep on, expenses that exceed her savings.
“And beyond that, I will probably go back to work doing what I do, which is working on my feet for 50 hours a week, perhaps before I’m before what the physicians would like to think of as 100 percent healed because I can’t afford to be out of work,” she said.
Donations have come in for Perez totalling over $1,000. The day Perez broke her ankle she and her band were supposed to play a show at the Bayview Pub. The gig went on as planned, but other musicians turned it into a benefit concert. Perez said she’s “extremely grateful” for all the help and for the government insurance that will keep her from facing a lifetime of debt. She just wishes everyone could have that luxury.
“I believe that governmental sponsored health care is essential, absolutely essential,” she said. “If anything it’s not far reaching enough.”