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This Is What All Americans Need to Speak Out For

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WASHINGTON (Medill News Service) -- Denise and Marvin Shaw did everything right. They both had good jobs, a nice home in Virginia and excellent health insurance through Denise's Fortune 500 employer. In the middle of a national health-care crisis, the Shaw's were secure and unafraid.
But in just over a year, and through no fault of their own, everything changed.
Their story illustrates the pervasiveness of the health-care problem in America -- even for those who have access to health insurance, the slightest wrong move not only threatens peace of mind, but a family's economic security.
It all began in 2006 when Denise, a 37-year-old Web developer from Chantilly, Va., was laid off from her job. She and Marvin fell back on the insurance program designed to tide people over in such situations, Cobra.
Cobra, an acronym for Consolidated Omnibus Budget Reconciliation Act, the federal law authorizing the program, requires insurers to provide temporary coverage to individuals who have left group insurance plans, often after losing their jobs. Cobra always costs more for the same coverage.
In their case, Denise was stunned to learn that their costs would go from $350 to $780 per month.
"My husband and I knew that we were getting, as my doctor likes to call it, the Cadillac plan," Shaw said. "So we said, let's just stay with it for 18 months and then we'll get our own plan."
At the time, the couple could have received coverage from Marvin's small company's plan, Shaw said, but it was "a bare-bones HMO," and they would have paid the same monthly fee.
Following her layoff, Shaw decided to work for herself instead of going to another large company. She did not think getting reasonably priced insurance would be a big problem. But by the time the Cobra coverage expired in September, she had spent months desperately searching for a replacement.
The Shaws decided to apply to Aetna because that's what they had when she worked for the Fortune 500 company. "They had all our medical records -- it should be easy, no problem," Denise said.
No coverage to be found
But no problem soon became no insurance as Aetna, and then company after company, refused to cover Shaw because she had two preexisting conditions: allergy-induced asthma and a benign pituitary tumor. Treatment for both conditions had been covered, without exception, under her previous plan.
As a last resort, the couple tried to get insured through Marvin's HMO plan. But they were told they couldn't enroll until February, then five months away. They were stuck, uninsured and uninsurable.
Shaw felt punished simply for receiving necessary health care. Had she not gotten treatment for her asthma, for instance, future insurance companies wouldn't have labeled it a "preexisting condition." She would have been considered lower-risk and her premiums likely would have been lower.
Relatively speaking, Shaw is healthy. She has never been hospitalized for her asthma, a condition shared by 22.2 million Americans, according to the American Lung Association. The tumor on her pituitary glad disappeared with medication, which Shaw continues to take daily to prevent its return.
"That's what really bugs me," she said. "This isn't like lung cancer. It never even occurred to me that (the tumor) could be an issue because it was benign."
Once Shaw's Cobra coverage expired, there was one hope: Under federal law, for 63 days after a person's health insurance benefits expire, any insurance company they apply to must agree to offer coverage.
The price, however, is left up to the individual health insurance providers.
The companies that eventually offered the Shaws coverage did so at devastatingly high rates. Aetna, for example, gave them two options: a $2,400 per month premium with a $1,000 deductible, or a $2,500 deductible for $1,800 a month.
"I said, unless you're going to turn around and send that money to BBT Mortgage, no, sorry," she said.
After those 63 days, Shaw would have become uninsurable. Because of her status as a provider "risk," unless she got another full-time job with a company that provided group benefits, she was unfit to be insured.
A costly solution
After a scary six-week period during which they were uninsured, the Shaws eventually did find coverage. Mega Life and Health Insurance Co., a provider Shaw found through a networking group, offered them coverage for just under $800 a month -- with a $10,000 deductible. The original deductible on their Aetna plan was $500 a month.
Over 18 months, then, the Shaws' health insurance costs increased by more than $5,000 per year, over $100,000 over 20 years.
And if a medical emergency arises?
"I'm still trying to figure that out," Shaw said. "Basically, we'll have to depend on the hospital taking a payment plan, at this point. I don't know how we'll do it."
Their struggles with health insurance changed their lives forever. After the new year, Shaw said, she'll consider taking on a second job, in case she ever needs to foot a $10,000 health care bill.
"It's funny," Shaw said. "I think if I knew then what I know now, would I do things differently (and forego treatment)? I don't really know the answer."
"That's pretty much how I feel: stuck. I never want to be in the same boat again."


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I think this is so sick.
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replied January 1st, 2008
Active User, very eHealthy
What do you propose Americans can do? How can we influence reform in the health care system?
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replied January 2nd, 2008
Extremely eHealthy
I personally have no clue what can be done but this is absolutely ridiculous. Letters need to be written to the government and action needs to be taken on a political level. The fact that Bush wants all insurance to become private is another step in the wrong direction.
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replied January 2nd, 2008
Extremely eHealthy
IF You are covered under a GROUP PLAN, you are LEGALLY able to get a plan even with pre existing conditions.

This is called the Helathcare portability act, or something like that.

IF you already have health insurance, you qualify for a plan without underwriting.

TO ME, this is a case of someone not knowing their rights.

I have 4 PRE EXISTING medical conditions, and because I know my rights, and know how to get documentation, I have never had problems with health insurance.
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replied January 2nd, 2008
Extremely eHealthy
THIS is from Aetna's website..

* Health benefits and health insurance are offered, underwritten or administered by Aetna Life Insurance Company (Aetna) directly and/or through an out-of-state blanket trust, and Aetna Health Inc. In some states, individuals may qualify as a business group of one and may be eligible for ***guaranteed issue, small group health plans.

THIS is an option for many people..

ALSO

The Health Insurance Portability and Accountability Act (HIPAA) provides rights and protections for participants and beneficiaries in group health plans. HIPAA includes protections for coverage under group health plans that limit exclusions for preexisting conditions; prohibit discrimination against employees and dependents based on their health status; and allow a special opportunity to enroll in a new plan to individuals in certain circumstances. HIPAA may also give you a right to purchase individual coverage if you have no group health plan coverage available, and have exhausted COBRA or other continuation coverage.
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replied January 2nd, 2008
Extremely eHealthy
Carifairy, I have a pre-existing and am applying for group coverage (Blue Shield Access Plus HMO) through my work. Does that mean they will cover my medical expenses? I have to go for another check-up soon...
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replied January 2nd, 2008
Extremely eHealthy
we need to figure out a way around exclusions--esp the ones that cost so much--like mine
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replied January 3rd, 2008
Extremely eHealthy
Irirdescent Opal-

YES, your group policy will cover pre existing conditions.

That is the biggest benefit of group insurance, it is GUANARANTEED issue, and has to cover your health problems.

I am not a fan of HMO because of the referral aspects, but Blue Cross and blue shield is known as the best in the industry!
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replied January 5th, 2008
Extremely eHealthy
Carifairy wrote:
Irirdescent Opal-

YES, your group policy will cover pre existing conditions.

That is the biggest benefit of group insurance, it is GUANARANTEED issue, and has to cover your health problems.

I am not a fan of HMO because of the referral aspects, but Blue Cross and blue shield is known as the best in the industry!


I have heard that how group insurance works in the company is that if there is people with chronic conditions and they spent this much money then the primes for the group goes higher too.
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replied January 5th, 2008
Extremely eHealthy
You really can't go wrong with Blue Cross Blue Shield. On the other hand, we are fighting with another company on my sons fairly large NICU bill that they are supposed to cover. We have to fight the large and small bills. It has taken so much out of us. It's so frustrating.

I have to say that we have been blessed to be covered for all of our preexisting conditions only because we have the group policy.

Not everyone is lucky enough to get a job where there is group coverage. They may work for a smaller company that is not required to offer insurance. My husband could never afford to be self employed. My next door neighbor is self employed; they own a book store. They have to pay over $1200 a month for health insurance because their daughter has a medical condition. Luckily, they are older and pretty much own their house.
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replied January 5th, 2008
Extremely eHealthy
Carifary,
what advice to you give people who can't find a good job with a company that offers group health benefits? What about people who do find a good job but it doesn't pay enough to afford the family medical plan? Just curious.

There are always situations that don't fall neatly in categories.
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replied January 5th, 2008
Extremely eHealthy
There are options...

A HIGHER deductible health insurance PLAN will be very cheap, but will still give protection from catastrophe.

EXAMPLE.. BCBS of NC has a policy with a 5,000 deductible, your maximum out of pocket would be close to 10,000..

You STILL get 30 doctor copay, and ER copay, RX discounts, etc..

BUT you have a higher deductible.

Say a hospital stay is 60,000$ With THAT plan the most you would be out is 10,000..

That is not as good as MY plan I buy myself, whcih is MUCH better, but it is certainly protection from massive bills.

There are options, people just need to educate themselves on plans.

The 5,000$ plan in my state is about 99$ a month!!

ALSO... IF you cannot afford health care for a family, then I would have people reconsider HAVING A FAMILY until they can afford health care. Or consider having fewer children so that THEY can afford to pay their own way.

Having a baby is not a necessity, but having health care is.

This is a case of realizing that people need to make RESPONSIBLE choices. Sometimes the most responsible thing you can do is not add to your family burden if you cannot afford it.
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replied January 6th, 2008
Extremely eHealthy
Carifary,

Some people have kids, can afford to get health insurance and then things happen. They may lose their job and then it's a downhill cycle.

I do agree that many people keep adding to their family when they can't afford it and expect our government to pay for everything. I see it all the time where I work and I get very angry. I think that is different than being in a situation where you make too much money to qualify for government assistance but not enough to afford the rising health care costs for a family plan. At my husbands work, it seems to go up $40 a year. We can afford it but many are can't because they make a lot less.

I don't understand what you are talking about where you say a $5000 plan in your state is $99. Can ANYONE get that? Is that with a specific insurance company or do you have to be in a certain low income bracket to get it? Is that with BCBS? When I ask "anyone" what about preexisting conditions? I have a hard time believing that someone with preexisting conditions can get a deal like that and not be in a group health setting by en employer. Please tell me more. BCBS definitely has preexisting conditions for someone who does not have a group health plan like you do. I would think that the $5000 deductible at $99 is for someone who has little, if any, medical issues. Is that price through a group health system?? So many questions.
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replied January 7th, 2008
Extremely eHealthy
YES, ANYONE can get it.

BCBC of NC accepts pre-existing conditions, but they charge you more.

A 5,000 deductible is a HIGH deductible, but 99$ a month IS for someone that has medical problems.

HIGHER deductible health insurance plans are cheaper.

99$ is NOT a group plan, it is an individual plan.

ANY health insurance company will charge you less for premiums IF you choose a very high deductible.

I pay 210$ a month, and I have 4 pre existing conditions. My deductible is 1,000$

Blue cross and blue shield of NC does accept people with pre existing conditions.
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replied January 7th, 2008
Extremely eHealthy
Carifairy wrote:
YES, ANYONE can get it.

BCBC of NC accepts pre-existing conditions, but they charge you more.

A 5,000 deductible is a HIGH deductible, but 99$ a month IS for someone that has medical problems.

HIGHER deductible health insurance plans are cheaper.

99$ is NOT a group plan, it is an individual plan.

ANY health insurance company will charge you less for premiums IF you choose a very high deductible.

I pay 210$ a month, and I have 4 pre existing conditions. My deductible is 1,000$

Blue cross and blue shield of NC does accept people with pre existing conditions.


If this is true, then people really don't have an excuse not to be covered unless they truly can't afford the $100/month.

I do believe a lot of people who say they can't afford that, really can. Some people are just used to government help and spend that money on other things like name brand items, new clothes and non-generic foods. I cloth diaper, recycle everything, am very frugal, go to thrift stores and buy inexpensive non brand name food. We do everything we can to raise my family, pay for our families health insurance, pay off (really pay down) my student loan, and we have a pretty good (very expensive due to preexisting conditions from my husband) life insurance. We even have insurance for our pets. I strongly believe in insurance. I, like so many people, are often under the impression that obtaining insurance with a preexisting condition is impossible. Thanks for the information.

I still have problem with the current system. There need to be changes but honestly I don't know which changes I am for: Republic or Democrat.
I have looked at both and see pros and cons of each. I am not as well versed as I need to be to really make a well-informed decision.
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replied January 8th, 2008
Extremely eHealthy
Ladylee- Some companies are well known for accepting pre existing conditions, and some are known not to accept conditions.

The best thing anyone can ever do is get insurance BEFORE you get to a place where you have health problems. Get insurance at age 18-25, when you are healthy, so at 40 when you may get hgih blood pressure, or something else, it is easily covered.

Plenty of people who CAN afford insurance just don't 'want' to pay.
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replied January 28th, 2008
health insurance
Okay guys, I have BEEN researching health insurance for a few months now. Yes, I neglected to keep the cobra on my wife after she left her job.
NOT CERTAIN THE COBRA WOULD BE HELPFUL,it was already MAXED OUT.
She has a spinal issue in the neck, so very pre-existing. The options are out of this world.

$800.MONTHLY AS AN INDIVIDUAL, BUT NO SPINE WORK FOR A YEAR... NOT GOOD.

$2000.MONTHLY AS AN EMPLOYER WITH 2 EMPLOYEES AND THAT IS TO MUCH, BUT INSTANT COVERAGE FULL BODY, WITH $1500. deductible.

We fortunate to be able to afford the $800., but waiting a year is not possible.

She has not exaclty been diagnosed with a pre-existing, but taking presrcibed narcotiCs for the pain... so all the insurance companies say she is pre-existing.

i like the $99., with big deductible. I am certain we got with BCBS and they, I think denied because "PRE-EXISTING"

WE ARE labeled AND THAT KEEPS US VERY MUCH WITH OUT OPTIONS

ANY DIRECTIONS GUYS?
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replied January 29th, 2008
Extremely eHealthy
fight for it-------Thas all i can say. I have blue cross blue sheild--some one said that you cant go wrong with them. well tell you honestly you can--they cut me off when i was 12 and havent cover anything since.
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