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Reform: immediate preventive care relief

Sick Americans holding out for ACA's pending provisions

Melissa’s husband was forced to get a new job just after she was diagnosed with breast cancer, even though he had insurance through his employer. It was the only way they could afford her treatments.

“We’d had a $10,000 deductible, and I was canceling follow-up visits and blowing off tests for Vitamin D, bone density, and others to monitor for progress and side effects,” says Melissa, 43, who holds part-time jobs as a teacher’s assistant and bookkeeper.”We just couldn’t afford the out-of-pocket expense or even the co-pays. Cancer cleaned out our savings, so there was no money to fall back on.”

The couple’s new plan – with a $6,000 deductible – still leaves the family strapped, and they have had to continue being resourceful. One resource: a Susan Komen grant that will enable her to continue participation in a clinical trial, which requires a battery of ongoing tests.

But Melissa is liking the one change brought about by the health reform act that directly affects her – and immediately. And she is especially happy about changes on the horizon.

“I am totally stoked that the new plan now covers mammograms as a preventive service with no out of pocket expense, not even a co-pay. The importance of my yearly mammogram is huge as it relates to early detection – which is key to overall survival should I have a recurrence,” says Melissa, whose breast cancer is an aggressive one with high risk for relapse.

She’s holding out for the bill’s pre-existing condition clause to kick in, slated for 2014. The provision not only prohibits insurance companies from refusing to sell coverage or renew polices because of a pre-existing condition, but also prohibits charging higher rates due to health status or gender.

2014 is also the “Year of No Annual Dollar Limits on Coverage.”

“I’m so looking forward to seeing that provision become effective. With cancer, you can’t predict the course of treatment – you don’t know what complications you may have that could land you in the hospital or how effective a regimen will be. Not to mention, cancer goes into remission, but there’s a big question as to whether it leaves your body forever. You just can’t put a dollar cap on it; there’s always the unexpected,” says Melissa.

An end to lifetime coverage limits

Jennifer, 35, has lived with mental illness for much of her life, and for years was up against the coverage limitations which have blown so many people in her situation out of the water.

“I, myself, have been discharged from hospitals before I should have been because of the lifetime limit, which for me was $50,000. That’s the cost of about three admissions.”

She hasn’t required inpatient psychiatric care for some time but is breathing relief that the new legislation                         is in place.

“This leaves me with one less stress to deal with. I know it will improve my life and that of countless others who have found themselves in the same situation as I have.”

Mental health advocates especially chock health reform up as a big victory for the population they serve – a population the Substance Abuse and Mental Health Services Administration disclosed has a higher mortality rate of any other in this country’s public health system. The average life expectancy for underserved people with mental illness now rivals that of HIV/AIDS patients. More reform initiatives are in the works.

“The health reform act will mean a lot of things for people with serious mental illness, and they are the ones most likely to be uninsured,” says Andrew Sperling director of legislative advocacy for National Alliance of Mental Illness (NAMI)

“Some of the areas we see having the biggest impact are new options in 2014 like the Medicaid expansion to include individuals at 133 percent of the poverty level and below. State-based exchanges for those above the poverty level will be big too.”

Jennifer not only is comfortable about the direction that mental health coverage is going, but is holding out alongside Melissa on the new pre-existing condition clause.

“My husband is asthmatic and has had to pay out of pocket for medical visits because his insurance company won’t cover asthma since he’s had it since childhood. When you tell a doctor your insurance won’t cover asthma, they require 100 percent payment at the time of the visit. Justin has had to go without care because of this,” says Jennifer.

Relief for pre-existing conditions is coming incrementally. As of 2010, it is illegal to deny coverage to children under the age of 19 due to a pre-existing condition. Coverage is also now available for adults who have been uninsured for at least six months because of a pre-existing condition. This program serves as a bridge to the 2014 ban on discrimination against pre-existing conditions, period.

Barb Dehn, a nurse practitioner in Silicon Valley, CA,  is seeing more traffic through her practice, as well as less reluctance among patients to come forward about their health issues, which she attributes to health reform.

“I’ve seen the legislation help hundreds of people who were denied coverage until this passed. They were not coming in because they were afraid to have any mention in their medical record of issues or concerns; they thought they could be turned down for coverage.

“I’ve had patients come in and take care of themselves because they no longer fear being put into a high risk group and thus becoming uninsurable,” says Dehn.

She feels confident the plan will help practitioners catch diseases and potential problems earlier; it already has.

“Just last week I saw a patient who had no insurance, went back on her parents’ plan, and was able to be seen for an abnormal pap. I have seen several patients in the last two months who had mammograms and colonoscopies because they are now covered. One of them had a pre-cancerous polyp removed from his colon. An abnormality was found on another of my patient’s mammograms. It was the first time she’d come in for this test in over two years,” says Dehn.

Other patients, especially those with complex medical problems and in very low-income brackets, are still holding out for insurance reform that will directly impact them. Susan W. is one of these people.

At 38 years old, she has liver and heart problems. She has fought cancer and ill effects of treatment. All of her teeth have broken off from chemotherapy, requiring extensive dental work, which she cannot afford and has no dental insurance. Susan is on disability and has no reserves to pay into the high-risk pools that are a component of the health reform act. She depends on state aid to help with basic health care.

“I am hoping that the long-term care insurance program that gives cash benefits to adults who became disabled (CLASS) will offer me some assistance. But that won’t happen until around fall of 2012. Also, if the health reform bill’s Medicaid guideline for 2014 would be put into effect immediately, I know I could benefit. But as of now, I continue to be denied.

Susan is on Social Security requiring that she wait two years to get Medicaid, so this is not an option now.

“The waiting is frustrating, because I was recently diagnosed with a late stage of triple negative breast cancer. It has a very high chance for recurrence in the first three years. I am in the most crucial period now, where I need help.”

For more on Affordable Care Act benefits to cancer patients:


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