Today a lot of people—last year, roughly 684,850 people younger than age 65—hear the diagnosis, “cancer.” Many of them function through treatment. We have drugs to ease the nausea of chemotherapy, drugs to relieve the fatigue, still other drugs to counter the depression.
Many patients, once diagnosed, survive both the disease and the treatment. These survivors encourage others to persevere through the regimens.
So the medical face of cancer is a hopeful one. Indeed, except for scarves to cover bald heads, cancer patients look like the rest of the population.
The American medical system, though, has added a new wrinkle to the face of cancer: penury.
The Kaiser Family Foundation/American Cancer Society gathered reports from 20 cancer patients—survivors—in “Spending to Survive: Cancer Patients Confront Holes in the Health Insurance System.” Policy-makers eager to maintain the country’s employer-based system of private insurance should read the tales.
The survivors, ages 10 to 62, had insurance at the time of the diagnosis. All underwent therapy. And, as therapy progressed, all became “medically bankrupt,” a term that lexicographers would define as “bereft of medical options.” But in this system’s health-speak, the definition is different: Their medical options didn’t run out, their money did.
The fine and not-so-fine print specifics of their policies gave their insurers numerable ways to say “no.”
• Caps. Survivors soon exceeded caps. One woman’s insurer capped annual payments at $2,500. Not surprisingly, she plunged quickly into debt. (Her breast reconstruction cost $56,000; she earns $2,100 a month). Even $100,000 caps did not suffice: patients soon exceeded them and were forced to delay treatment, or go into debt. One woman who exceeded her $100,000 cap owes $75,000; bill collectors call her nightly.
• Co-payments. A $25 co-payment for an office visit for a healthy person isn’t onerous. Three $25 co-payments a week will mount up—as will 30% co-payments for chemotherapy or radiation. This comes after the patient paid the $2,500 deductible. One patient put all bills on a credit card, letting the balance creep up. Another patient used up his 401K.
• Pre-existing conditions. If cancer is a pre-existing condition, an insurer can refuse to cover it. Federal legislation requires that a new insurer cover all “pre-existing conditions” if a person has been insured for 12 previous months. One of the Kaiser patients had been insured only 9 months before switching insurers.
• Out-of-network providers. Employers can switch insurers, which means a new set of “network” providers. Insurers can change their “networks.” And physician-groups can drop their “network” status. One patient discovered that the physicians she had started with were no longer in the “network.” Often patients must switch providers, or pay most of the tab. Some networks don’t include crucial sub-specialists.
• Finally, patients fell into the post-employment pit, when their private, work-based insurer dropped them. Not surprisingly, some patients found it hard to continue working full-time. Their options for continued coverage were grim.
COBRA is the chief recourse. Employers must offer employees who leave the option of paying the full tab for group insurance for up to 18 months. But COBRA premiums are costly. One patient paid $704 a month; their family income came to $40,000 a year.
Another recourse is the private market, but the private market does “medical underwriting” and might refuse to cover a patient’s cancer treatments, or charge a stratospheric premium, higher than COBRA.
As for high-risk pools—the state mechanisms designed to help people who are “uninsurable”—only 35 states have them; and some states have shut enrollment. Florida stopped enrollment in 1991. Patients who can enroll in those pools will pay exorbitant premiums: one patient discovered that her state’s high-risk pool had a 12-month waiting period, and charged $814 a month. If she qualified for a low-income subsidy, the premium would drop to $504 a month.
And the safety net in public programs is porous. Medicare will cover disability, but a prospective enrollee will need to be covered under SSDI for two years beforehand. Medicaid has eligibility rules, as well as income thresholds. A person who works full-time, even earning minimum wage, is probably not eligible for much help. And states have their own cruel roadblocks; e.g., one woman was not eligible for treatment of cervical cancer because she did not have Medicaid at the time of diagnosis.
The report estimates that one in 9 cancer patients will pay more than 20% of their family’s after-tax income for treatment. Those are patients with insurance.
The solons and wonks who want to maintain this status quo should read these tales of people who survived cancer, but fell victim to a bizarre health system designed to safeguard investors’ returns and executives’ salaries.
Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email retsinas@verizon.net.
From The Progressive Populist, March 15, 2009
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