The Affordable Care Act: Healthier for it

President Obama’s signature legislation is already making a difference in SLO County residents’ lives, as these three stories illustrate

bcuddy@thetribunenews.comSeptember 14, 2012 

A few weeks back, I excoriated the national press for reporting on health care as solely an economic and political issue. I chided them for failing to put a human face on it and talk about people who already are benefiting.

Then it occurred to me that I should put my money where my mouth is, walk the walk instead of just talking the talk. (Insert your own cliché here.) So I began to look around San Luis Obispo County for people who are living healthier lives because of the Affordable Care Act. They weren’t hard to find.

I thought you might like to meet some of them and maybe even use their experiences as a guide to get the health care help you need.

Help with prescription drugs, to cite just one of many examples. Secretary of Health and Human Services Kathleen Sebelius recently said seniors and people with disabilities in California have saved $340.6 million on prescription drugs.

This is not, however, an analysis of the Affordable Care Act. I am not looking into the pros and cons of the 2,700-page legislation. There is plenty of that sifting already taking place out there.

I know many people fear the ACA, and I leave others to engage in that discussion.

This package is about people.

You can find their tales in the accompanying stories. I do want to note a couple of common threads, however:

• You have to fight like a bulldog, as Diane Burkhart put it, to get the coverage to which you are now entitled;

• You should, as both Burkhart and Don Funk said, spread the word.

• You might need a “navigator” such as Susan Polk, to get you through the new world of health care.

On that point, Polk, interviewed for this story because of her particular expertise, is not looking for medical insurance like the other people profiled here, and if she were she would know how to proceed: She is a health insurance broker.

“This is going to be confusing,” Polk said of the Affordable Care Act. “People get turned down, they give up. They don’t know what is available.”

She says the act already is hard to understand, and will become more so when other aspects kick in in 2014.

In addition to the federal law, she said, the state has enacted laws “to move health care reform more quickly, so we don’t have to wait until 2014, when the law becomes more fully effective.” Among those are guaranteed insurance for children and a law that all individual plans in California, including existing plans, have to cover maternity expenses.

To me, the material was almost indecipherable. But that is where professionals like Polk come in. She says there are hundreds of brokers just in the county.

All of us who can’t wend our way through the health care morass on our own are, in my view, going to have to become proactive and find people like Polk.

The Affordable Care Act has changed things dramatically. It’s time for us to learn how.

One final thought, to tuck away and revisit in a few years: Although “Obamacare” is a pejorative today, a growing number of people think it will have a positive connotation in the future, as its benefits become known and utilized.

In 25 years, said Kena Burke of Community Health Centers, “nobody’s going to care. They won’t understand what people were so upset about.”

Donald Funk: Little-known provision opened door to coverage

For most of his life, Donald J. “Deej” Funk of Paso Robles says, he was a pretty healthy guy.

“I was rarely sick, at most three or four days a year. I seldom went to the doctor.”

Then, eight years ago, when he was in his mid-50s, disaster struck. He began to feel weak, and the debility progressed.

“I couldn’t hold a toothbrush,” he said.

He eventually was diagnosed with Guillian-Barre syndrome.

He fought his way back — a grueling battle whose health care costs were mostly covered under his employment contract.

Flash forward a few years — Funk, 64, found himself laid off. His health insurance had long since gone, as had his COBRA coverage.

He wanted health coverage again.

But he couldn’t get it.

Funk “started applying everywhere.” The answer was always the same.

Even though he took good care of himself, he had a medical history that scared away insurers. Even his previous insurer turned him down.

“So I said, OK, I’ll just have to do without insurance, like a lot of people do.”

But that began to “unnerve” him, filling him with anxiety about the future. “Oh my gosh, it’s awful.”

He thought of scenarios that were not implausible should he become ill again.

“You could lose your house,” he said, as so many unexpectedly ill Americans have under the current health care system.

“I said, ‘I have to have some kind of insurance coverage.’ ”

He stepped up his efforts and discovered something called the Pre-existing Condition Insurance Program — PCIP. It is available through the state and exists because of the Affordable Care Act.

The PCIP card is not a freebie, paid for by other taxpayers. Funk foots the bill. There are hoops for the insured to jump through — high deductibles, for example.

There is a sliding scale for costs, and Funk’s premium is $530 a month, with a $1,500 “in-network” deductible and $2,500 out of network.

The numbers, however, seem almost secondary. The point is that Funk now has coverage, and everything that goes with it, not least of which is peace of mind.

It’s important to Funk that other people know about the PCIP. He is trying to get the word out.

“No one should have to worry that their health won’t be cared for,” Funk said. “I feel very strongly about that. It’s just like all of our other rights.”

-- Bob Cuddy

Diane Burkhart: Careful research revealed many benefits

Diane Burkhart, who has benefited from the Affordable Care Act, has some advice for others wishing to do the same: “Dig like a bulldog” because nobody in the industry or the government will smooth the way for you.

Burkhart and her husband, who are in their early 50s, live in rural Paso Robles. She says health insurers don’t make it easy for their customers to learn about new benefits, and she also criticizes the Obama administration for not getting the word out adequately.

The Burkharts are poster children for how you can lower health care costs through the ACA if you take the time to navigate the system. They’re also exemplars of the act’s emphasis on prevention.

Here are some of the things Burkhart eventually learned she and/or her husband can secure under the ACA: free skin cancer screenings, pap smears, mammograms and colonoscopies, blood tests, annual checkups and a $20 eye exam.

These are considered adult preventive services, and are not just for people older than 50.

“In the half-inch-thick guide to my benefits is the following sentence,” Burkhart writes:

“Coverage for preventive benefits, as defined in the Act, does not require any deductible, co-payment, or co-insurance if obtained from a participating provider.”

There is much more, including well-baby coverage, and Burkhart says to find them the patient health care user should go to www.healthcare.gov or other sites noted in a breakout listing published with this article.

The focus on prevention is a key philosophical and economic component of the act. The idea is, if you prevent illness, not only will people be healthier and more productive, but the government will save money in the long run because people will go to the hospital less often.

It took a while for the Burkharts to get to the less-anxious point at which they have arrived.

Interviewed at her home, Burkhart told a harrowing tale of watching health care premiums grow by double-digit jumps in the past decade. They were “incredible increases,” she said.

After the ACA became law, she said, her insurer tried to warn her about the dangers of making changes.

“They made it so you were afraid to risk what you had, even though what you had was lousy.”

She said she made numerous phone calls to her insurer, who steered her to programs that weren’t to her advantage.

Finally, she and her husband received one rate boost too many and she “became proactive.”

“My husband is a handyman; I’m not working. We have to be careful” about expenses, she said.

Burkhart had help. She has a neighbor who knew how to navigate the byzantine health care system, and a local insurance broker helped. She knows not everyone is that fortunate.

Burkhart would like to see the federal government get the word out more effectively.

“When I tell people how much we have benefited from health care reform, they are surprised,” she wrote to President Obama.

“I believe your team needs to make a bigger effort to inform the public about the options available to them that the insurance companies are not advertising,” she wrote.

--Bob Cuddy

Malcolm Brudigam: Student back on his parents’ health plan

For 19 years, Cal Poly student Malcolm Brudigam was covered by his parents’ insurance plan. But in February 2010, after Brudigam turned 20, his coverage ended.

At the time, insurance companies could remove enrolled children from their parents’ plans at age 19. Brudigam, who grew up in the Bay Area community of Lafayette, was no exception.

“I remember my parents were trying to figure out what to do,” Brudigam, 22, recalled recently.

His parents considered leaving him with the coverage offered by the university. Or, they could have signed him up for his own plan — a costlier option.

Fortunately for Brudigam, the Affordable Care Act was passed about a month after his 20th birthday, and he was allowed to rejoin his parents’ insurance. Under the law, most health plans that cover children must make coverage available to dependents up to age 26.

“I remember saying, ‘This is great,’ because my dad didn’t vote for Obama and now we’re getting some benefits out of it,” he said.

Having health insurance gives Brudigam peace of mind knowing that he’s covered in case something happens.

“I’m young and I like to think that I’m healthy,” he said. “But I am a cautious person … driving is one of the most dangerous things we do, and it’s nice to know that I won’t have to worry about any bills if I do go to the hospital.”

Brudigam studied environmental science at Cal Poly. He graduated this summer and is applying for jobs in the public and private sector. If a future employer offers health insurance, he’ll be off his parents’ plan again.

But for now, it’s one less thing to worry about.

--Cynthia Lambert

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