A Personal Perspective on Health Insurance, Kids & Health Reform

Health insurance and childrenWith health care reform back in the news following the recent decision to institute a one-year delay for the large employer requirements and some Republican calls for a delay also to the individual mandate, I thought it would be a good time to tell a story that demonstrates the human cost and impact on children of our health insurance system – and the value that one family at least will find from the opportunity to purchase individual health insurance through the exchanges that are currently still required to start operating on October 1st of this year.

Through my studies for a Master’s degree in public health (almost finished!) I have heard different parts of the US health care system likened to Britain’s National Health System or NHS (regarding Medicare – coverage for our oldest citizens), to Germany’s social insurance system (regarding our employer-provided health insurance) and to any of a number of the least developed and poorest countries in the world when considering the uninsured in America who are too poor to pay for health insurance.

However, you do not need to be poor to find access to good quality, affordable health insurance a challenge. A 2013 Gallup poll found that employer-based health insurance has decreased for all income groups over the past 4 years – with the largest reductions for middle income individuals earning between $36,000 and $90,000 a year. Only 45% of Americans now receive health insurance through their employers, due to both recent increases in unemployment and an increasing trend for employers not to provide health coverage.

My good friend and hairstylist extraordinaire, MaLisa, is an excellent case in point. As a hairstylist, she is a self-employed business woman – and also the main earner for her family with her husband at home looking after their two children. Given her situation, MaLisa is forced to purchase health insurance in the individual market, trying to balance the high cost of premiums with the risk of substantial health care costs from her son’s severe asthma or her husband’s auto-immune condition.

Despite paying premiums of $800 per month – nearly $10,000 EACH YEAR – no one in MaLisa’s family is covered for any health care costs until a $5000 deductible PER PERSON has been paid out of MaLisa’s own pocket. So if each member of her family was significantly ill in a year – including herself – she could end up paying $20,000 on top of her $10,000 in premiums before getting any insurance benefit. And even though the deductible for her son has already been met this year – due to an acute asthma flare-up that required a 4-day hospital stay – the family is still required to pay over $740 per month for his expensive medication regimen, something they aren’t sure how they will manage given all the medical bills piling up. Cheaper drugs aren’t really an option as that’s what he was taking before recently being admitted to the hospital. Hospital staff half-jokingly asked if they could move away from Indiana, to a state that isn’t so bad for allergies or asthma.

A health insurance plan that MaLisa carried for a while from a previous employer did have somewhat better coverage and lower deductibles – but the COBRA rates were increasing exorbitant – at one point rising to $1400 per month (an annual cost of nearly $17,000). How many families can afford this level of fixed cost in their budget? Though my friend did ruefully admit that – in hindsight – it might have been better to pay these higher upfront costs given the level of health care issues their family has faced. Right now, she is just counting the days until 2014 when the individual health insurance exchanges are expected to begin operating under the Affordable Care Act – so that she and her family can access decent healthcare coverage at a rate that doesn’t present such dire financial consequences.

And my friend’s family has already benefited from health reform, since as of January, 2013 health insurers have been required to provide coverage for children for pre-existing conditions. Until that mandate came into effect, MaLisa couldn’t change insurance plans or her son’s asthma care would have been excluded. However, she had to fight for even this small improvement. Despite all the press about health reform, neither her health insurance carrier nor Indiana’s State Insurance Commissioner had any idea what she was talking about when she contacted them to say that her son had the right to this benefit. Coverage wasn’t forthcoming until she sent copies of the legal statute by registered mail to these supposed insurance experts. It just shows that it pays to do your homework and advocate for you and your family given all the changes in the health care environment.

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About the Author

Audra is an experienced pharmaceutical marketing professional, aspiring writer, and mother of Elliott, a high-spirited twenty-year old. Frequently tired but never bored, she has a strong interest in public health fostered by numerous years implementing global oncology education programs as well as by her twenty-year crazy (wild? amazing?) adventure in parenting. She recently earned a Masters in Public Health to augment her expertise in health policy and health promotion. Audra is a founding member of the PedSafe Team


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