"The Other Side" Has No Clue About Getting Insurance on One's Own


(Interview 2013. Oil on linen, 40 ins. x 30 ins.)


2021 Update

I reached out to find out what is going on with this subject. Her husband is still at the same job. His employer has not provided group benefits for quite some time. He had stopped providing benefits before the implementation of the Affordable Care Act.


The employer's former insurer agreed to sell her family a single policy after the employer dropped his group plan. But the insurer raised the price every six months. (This all happened before the subject got relief from the Affordable Care Act)

“Extreme stress was mounting. How was this going to end? This situation was not sustainable.” The subject said. “I felt terrible. I couldn’t sleep. I had digestive problems. When the employer dropped the insurance, I knew nothing. I had to figure it all out. I thought I would get a policy and the price would stay the same.”

Today the business owner's employees go the the Affordable Care Act (Obamacare) marketplaces. Here is what she said when I asked if there were any problems with the insurance. "No but I’m not sure how next year will go. Just take it year by year. Insurance is great."



Artist Note (2013)

“Insurance is a totally different feeling now. People who get insurance through work have it cushy. They don’t care about Obamacare. They don’t know what it’s like on the other side.”


The “other side” the subject refers to is the frightening place where her husband’s employer -- a small business owner -- dropped the health insurance benefit for his employees altogether because his insurance company raised his rates too high. The employer could no longer afford the premiums.


Annual premiums for employer-sponsored family health coverage reached $21,342 this year, up 4% from last year, with workers on average paying $5,588 toward the cost of their coverage.

The subject made herself sick worrying about finding insurance for her family on the individual market (before the Affordable Care Act). She put off her own medical care. She spent hours trying to learn how to navigate the insurance world like a dingy among freighters dwarfed in the shipping lanes. She was scared. What if she could not find insurance for her family? A very real fear.


The 2010 healthcare law / Affordable Care Act / Obamacare has gone a long way to relieve the stress this subject endured. But she still feels at the mercy of the insurance companies.


Here is her portrait story.

 

A study. Oil on canvas, 24 ins. x 18 ins.

(from a 2013 interview)

Stay-at-Home-Mom, Age 44, Insured

The subject fulfilled a lifelong desire to be a mom when she married at 22 years old, and soon became the mother of twins in 1994.


Her medical bills for the first pregnancy were covered under her husband’s insurance policy through his work. His employer had a group health plan in place. At the time, 5 people comprised the employer’s small group. The benefits were comprehensive and generous. Maternity was a covered service.


By time she delivered the last of her ten children, the subject had a a health maintenance organization (HMO) policy through her husband’s employer. To get her medical bills paid, she had to choose providers from the plan's network. The HMO covered less compared to the policy she had for her first delivery in the 1990s.


Was the employer was trying to control his spiraling insurance premiums by offering less generous policies every year. This has been a typical strategy for many employers including me when I co-owned a small business.

Choice is a funky word when describing what the American people want in health plans. We want a system that works and doesn't scare the hell out of us if we get sick.


For employees with group plans, their choices are limited. The employers not the employees are the ones with the choice. Employers choose which health plans to offer the employees in the group. Employers' choices, however, are limited to what they can afford. Spiraling premiums are the ever-rising tide drowning very small businesses. A 2020 Kaiser Family Foundation Employer Survey reported.


Annual premiums for employer-sponsored family health coverage reached $21,342 this year, up 4% from last year, with workers on average paying $5,588 toward the cost of their coverage.


No choice has become a talking point for those opposing progressive healthcare reform. In fact, to his "everlasting regret" Wendall Potter, former vice president of corporate communications for a leading insurer, says he is responsible in large part for the fallacy that systemic health reform would limit consumers' choices. "To my everlasting regret, I played a hand in devising this deceptive talking point about choice when I worked in various communications roles."


~


The subject's last child was born premature. Her baby’s medical bills totaled over $1.5 million. The insurance did not cover the entire bill. A social worker at the hospital suggested she apply for state financial assistance, which she did. Babies with low birth weight are eligible for Medicaid insurance coverage.


About a year and a half after the premature birth, her husband's employer stopped offering insurance to his employees altogether. Premiums for the group went up a “couple thousand a month. He could no longer afford it,” the subject said. “I believe my family’s high claims with the premature birth, and claims from other employees with medical problems, caused the insurance company to raise the premiums so high that my husband’s employer had to drop the insurance." (The Affordable Care Act has since established consumer protections for individuals and small businesses.)


Employees now had to shop around for insurance on their own on the individual market. The employer would make a contribution to help his employees buy individual policies.


With employer contribution in hand, the subject had to find some kind of policy on the individual market that would provide comparable coverage to what the subject was getting through her husband’s employer. (The Affordable Care Act had not yet been implemented.)


The same insurance company that provided the group insurance to her husband’s employer, also agreed to sell her an individual family plan. The family qualified without regard to preexisting conditions -- a reason so many were denied insurance on the individual market -- because the family had 18 months of continuous coverage without a gap of more than 63 days as per the HIPAA law. Without the family’s uninterrupted insurance group coverage, the family’s preexisting conditions would have most likely precluded them from getting insurance on the individual market.


Although the HIPAA law made it easier for those insured without breaks in coverage to buy a single policy from the insurance company, the law did not limit how much the insurance company could charge for those individual policies.


At first, the employer contribution covered the cost of the new family premium on the individual market. Six months after coverage started, the premium went up $100. Six months after that the premium went up again. But the employer contribution stayed the same. The employer was not increasing his contribution, and the family did not have the money for continual premium increases.


“Extreme stress was mounting. How was this going to end? This situation was not sustainable.” The subject said. “I felt terrible. I couldn’t sleep. I had digestive problems. When the employer dropped the insurance, I knew nothing. I had to figure it all out. I thought I would get a policy and the price would stay the same.”


“I started to become afraid to use my insurance. I would not go to the doctor if I needed to. I thought if I did, my premiums would go up even more.” The subject needed an MRI but she put it off.


When the subject got a letter from the insurance company saying the premium would be $1600/month, she knew she couldn’t afford it. “I was in tears.”


She had heard about Obamacare,” the Affordable Care Act. Maybe she could get a policy on the new Obamacare marketplace? She would have to hold on. The year was 2013. The Affordable Care Act marketplace did not start until January 2014.


Like most people trying to buy insurance on the marketplace during the first open enrollment period in late 2013, the subject had difficulty getting her application processed due to the healthcare.gov website malfunction.


Eventually the subject did get insurance for her family through healthcare.gov. The policy start date was January 1, 2014.


The subject’s husband’s employer gave him a raise since he was not providing any kind of health insurance benefit to his employees. (The employer had stopped providing benefits before the implementation of the Affordable Care Act.)


The subject plugged in her family’s details –children, ages, income, etc. -- into the marketplace website. With her husband’s raise, the subject was able to purchase a plan she was happy with. The plan covered her family. The co-pays and out-of-pocket expenses were affordable. She qualified for a subsidy, financial assistance, to purchase a family policy. The website also said one of her children qualified for Medicaid , and the other would go on CHIP, the government's health insurance program for children


The subject is relieved to be off the downward spiral of trying to fend for herself in the open seas of the individual market before the Affordable Care Act became law. She feared she would have been priced out of insurance because her premium was going up every six months. “And then what was I supposed to do?” She had no employer-based insurance, and was not able to afford insurance on the individual market before the Affordable Care Act.


The subject still has misgivings about access to insurance even with the ACA. “As long as insurance companies can do what they want, eventually we’ll all be in the same boat.” She does not believe our current system is sustainable. “ Some things need to be addressed. A lot of doctors don’t take Medicaid. But CHIP is good. “


The subject’s insurance company made a billing error. “I feel like they are so in control of my life. I couldn’t use the plan for 4 months. I’m at their mercy. I had to cancel heart and gyno doctors’ appointments. That’s not normal. THEY screwed up my bill. When I called, the insurance companied transferred me all around. Nobody called me back. It’s unacceptable. They couldn’t care less. We’re paying good money. I couldn’t handle it. I was crying on the phone. One child needed blood work.


“Finally one friendly guy went through all the billing. ONE guy listened, and the issue got resolved. Our whole life is in their (insurance company) hands. They have all the power. No recourse for me. It’s a terrible feeling. I was told that when the billing got resolved, claims would get paid. Guess what? That didn’t happen. It was too complicated.”


After all the subject has been through trying to keep her family insured, she offers this last thought. ”Insurance is a totally different feeling now. People who get insurance through work have it cushy. They don’t care about Obamacare. They don’t know what it’s like on the other side.”