A law that scraps junk insurance

by Timm Herdt, Ventura County Star

Amid all the noise that has been generated over the past month about whether insurance policies should be required to cover contraceptive care, barely a whisper has been raised about the underlying concept that made this an issue in the first place.

Here’s the concept: When consumers buy insurance, they should get a product of value that covers the essential health care services they need and expect it to cover.

Forget contraception for a moment and think about its flip side: maternity.

In California today, nearly 90 percent of health insurance policies sold on the individual market do not cover prenatal care or labor and delivery costs. That will change on July 1, when a new statewide maternity-care mandate kicks in, and nationwide in 2014, when the federal Affordable Care Act goes into full force.

But for now, this is the reality for women of childbearing age when they shop for insurance: The most likely significant health care cost they will incur is pregnancy, but it’s entirely possible that the insurance they buy will cover neither the cost of preventing pregnancy nor the costs of delivering a baby.

For them, having such an insurance policy is akin to owning a car that doesn’t start and has no brakes. You make the car payments every month, but still have to ride a bus to work.

As Friday’s second anniversary of the Affordable Care Act ‘ you may know it as "Obamacare" ‘ approaches, consumer advocates are reminding people that one of the benefits of health care reform is that it ensures that insurance policies actually provide the services for which consumers believe they are paying.

"People really don’t know what they’ve got," said Betsy Imholz of Consumers Union, speaking Tuesday at an event in the state Capitol celebrating the second anniversary of the health care act. "People often end up with, frankly, junk insurance. The act aims to ensure that essential services are covered."

"A very important part of the Affordable Care Act is getting rid of the fear of fine print that so many consumers have ‘ the fear that they will fall through a loophole," said Anthony Wright, executive director of the health care advocacy group Health Access.

Such "loopholes" can be of much greater financial consequence than, say, having to pay out of pocket each month for a prescription for The Pill.

For Bill and Victoria Strong of Santa Barbara, the loophole-closing aspect of the law has protected them against the possibility of financial ruin as they care for their terminally ill 4-year-old daughter, Gwendolyn.

As a couple in their late 20s, the Strongs purchased a very good health insurance policy with a lifetime benefit limit of $5 million. In their early 30s, they had a daughter. When Gwendolyn was 6 months old, she was diagnosed with spinal muscular atrophy, a degenerative condition similar to ALS, or Lou Gehrig’s disease.

Most children with SMA don’t survive beyond age 2.

"My daughter is an outlier," Strong told me Tuesday. "We’re lucky to have her with us still."

Gwendolyn is completely paralyzed, and any minor illness threatens to shut down her respiratory system. She has 24-hour care at home, and that, coupled with her frequent visits to hospital intensive care units, runs up medical bills of about $1 million a year.

Before the law passed ending lifetime limits on insurance benefits, Strong said that "every day she remained alive we marched toward a cliff. We were very quickly headed for financial ruin."

Beginning in 2014, the Affordable Care Act will limit annual out-of-pocket costs at $5,950 for patients with cancer, multiple sclerosis and other chronic conditions that are expensive to manage. Drug therapies can cost several thousand dollars a month.

Speaking this week at a news conference promoting a bill that would accelerate that requirement by one year in California, the director of Sacramento’s Mercy Multiple Sclerosis Center said the benefit would be enormous.

"For many medical conditions, we’ve seen an increasing number of medications that for the very first time can slow or prevent regression," said Dr. John Schafer. "It’s disheartening when I see patients who would greatly benefit from these medications not take them because their insurance won’t cover them, even though they thought they had insurance."

At its core, that’s what the Affordable Care Act is about: making certain that when Americans purchase health insurance they will receive a product that delivers what they’re paying for ‘ the peace of mind of knowing that if catastrophe strikes they will be protected.

"It really can happen to anyone," Strong told me. "You don’t think about these things until you wish you had."