Janet’s Story: High medical costs, worse coverage


Janet reports, “In 1999, I was diagnosed with Hepatitis C, which made me ineligible for insurance (denied for pre-existing conditions).  I live in Colorado, and they had a high-risk pool that covered people like me. I applied for that and was accepted.

“My premiums in 2010 were $275/month with a total out of pocket of $2,500.  [While I was on] this plan, my liver failed, and I needed a liver transplant. It was approved without a question.  My $600,000 transplant was covered 100% with a $2,500 out of pocket maximum!

When Obamacare went into effect, Colorado’s high-risk pool was closed.  “I was forced into the regular marketplace that everyone was telling me was a good thing because I couldn’t get denied.  I think my first year on that policy, my premiums were in the $450 range—which I thought wasn’t too terrible, but still more than I had been paying.

“The thing I noticed from the start was that instead of full coverage, almost everything I needed was denied, which threw me into the world of having to appeal (sometimes several times) to get the basic care I needed.

“Since then, my premiums skyrocketed. In 2017, I paid $735 a month with total out-of-pocket costs of $5,500.  In 2018, my premiums went up to $1,100 a month with a deductible of $6,300.  Once I hit that mark, I’m covered 80%.

Further, none of my anti-rejection meds are on the formulary of my insurance. If I could not afford them, my body would most certainly reject my liver, causing another liver transplant that would not be covered 100%.

“I don’t get any credits from the government to reduce my premiums.  Those of us who are self employed, but make more than the threshold for tax credits wind up footing the whole bill ourselves.  I have to spend $19,500 before my insurance pays anything, and it doesn’t cover all my prescription costs.  My old plan was almost a third of what I have to pay now.

“I have many friends and work associates in the same boat as me.  Many of them are doing without insurance and are betting that they won’t need more than what they can afford to pay out of pocket.  I cannot do that, because if something happened and I needed another transplant, it would bankrupt my family.

“The system is broken beyond imagination.”

How our plan would help:

Janet is an example of a patient who needs extra help with medical expenses.  Putting her into the same insurance pool with everyone else means her special medical needs aren’t being met and that she, along with everyone else in the pool, must pay higher and higher costs for insurance.

Under our plan, Colorado could revive the high-risk pool that worked for Janet before Obamacare.  Or the state could create new ways of providing extra help for people like Janet with expensive medical conditions so she can get the medicines and treatment she needs while keeping her premiums and deductibles at a more reasonable level.

Under our plan, states would need to show that a fixed percentage of the grant money is being spent on those with greater health care needs. Obamacare does not do this.*  And our plan does.

*Obamacare initially provided funds for a federal high-risk pool, but that ended as the exchange coverage began.