For one woman with cancer, Obamacare means loss of coverage for an essential drug

 

By Jennifer Popik, JD, Robert Powell Center for Medical Ethics

claimrejectedAs millions of Americans are attempting to start using their new Obamacare exchange health insurance plans, stories about denial of payment keep piling up. All throughout the debate leading up to the controversial 2010 law, and up until late last year, the Obama Administration kept asserting that “if you like your plan, you can keep it.” But by last December, the fact checker PolitiFact was awarding this assurance its Lie of the Year for 2013.

When hundreds of thousands lost plans they liked, the administration moved on to its next claim–that “the new exchange plans would be better than your old plan.” This new promise is already proving to be at odds with the facts.

A February 23, 2014, Wall Street Journal piece illustrates the heartbreaking consequences of being forced into an Obamacare exchange plan that will not pay for a cancer-fighting drug – a denial traceable to provisions in the law that have the effect of forcing reduction in America’s health care usage.

Under the title “Obamacare and My Mother’s Cancer Medicine”, Stephen Blackwood chronicled his mother’s struggle to find coverage in a post-Obamacare environment. He wrote, “The news was dumbfounding. She used to have a policy that covered the drug that kept her alive. Now she’s on her own.”

In 2005, at age 49, his mother was diagnosed with a rare cancer. The cancer is terminal. However, it typically responds to a drug called Sandostatin that slows growth and reduces symptoms. Blackwood wrote

“And then in November, along with millions of other Americans, she lost her health insurance. She’d had a Blue Cross/Blue Shield plan for nearly 20 years. It was expensive, but given that it covered her very expensive treatment, it was a terrific plan. It gave her access to any specialist or surgeon, and to the Sandostatin and other medications that were keeping her alive.

“And then, because our lawmakers and president thought they could do better, she had nothing. Her old plan, now considered illegal under the new health law, had been canceled.”

His mother, a former medical-office manager, no stranger to navigating insurers, was unable to use the Virginia exchange, and called around to individual exchange insurers. After she spent days and weeks of searching, no one could tell her for sure if her drug was covered.

Finally a representative for one plan, Humana, told her that her drug would probably be covered. Unbelievably, this was the closest to a firm commitment she could get from any insurer. According to Blackwood,

“With no other options, she bought the plan and was approved on Nov. 22. …Then on Feb. 12, just before going into (yet another) surgery, she was informed by Humana that it would not, in fact, cover her Sandostatin, or other cancer-related medications. The cost of the Sandostatin alone, since Jan. 1, was $14,000, and the company was refusing to pay.

“The news was dumbfounding. This is a woman who had an affordable health plan that covered her condition. Our lawmakers weren’t happy with that because . . . they wanted plans that were affordable and covered her condition. So they gave her a new one. It doesn’t cover her condition and it’s completely unaffordable….

“But there is something deeply and incontestably perverse about a law that so distorts and undermines the free activity of individuals that they can no longer buy and sell the goods and services that keep them alive. Obamacare made my mother’s old plan illegal, and it forced her to buy a new plan that would accelerate her disease and death. She awaits an appeal with her insurer.”

While many are quick to blame insurance companies, the real culprit is the Obamacare provision under which exchange bureaucrats must exclude insurers who offer policies deemed to allow “excessive or unjustified” health care spending by their policyholders.

Under the Federal health law, state insurance commissioners are to recommend to their state exchanges the exclusion of “particular health insurance issuers … based on a pattern or practice of excessive or unjustified premium increases.” The exchanges not only exclude policies in an exchange when government authorities do not agree with their premiums, but the exchanges must even exclude insurers whose plans outside the exchange offer consumers the ability to reduce the danger of treatment denial by paying what those government authorities consider an “excessive or unjustified” amount.

This means that insurers who hope to be able to gain customers within the exchanges have a strong disincentive to offer any adequately funded plans that do not drastically limit access to care . So even if you contact insurers directly, outside the exchange, as Blackwood’s mother did, you will find it hard or impossible to find an adequate individual plan .(See documentation at www.nrlc.org/medethics/healthcarerationing.)

When the government limits what can be charged for health insurance, it restricts what people are allowed to pay for medical treatment. While everyone would prefer to pay less–or nothing–for health care (or anything else), government price controls prevent access to lifesaving medical treatment that costs more to supply than the prices set by the government.

More on declining coverage can be found here.

While Obamacare continues to roll out in 2014, it is important to continue to educate friends and neighbors about the dangers the law poses in restricting what Americans can spend to save their own lives and the lives of their families. You can follow up-to-date reports here: powellcenterformedicalethics.blogspot.com

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