We have a double mastectomy patient. She is illiterate and lives alone, so she doesn't have daily assistance in understanding health insurance information or in navigating the marketplace. Even after she transitioned to ACA coverage, she called Martha Ware, RN, our Women's Health Director, a couple times a week. She called (and continues to call) to talk about not just her health challenges, but her life in general. Martha is her therapist and case manager and nurse and friend all rolled into one. When I called to interview this patient, she said she only wanted to talk to me if Martha was on the line too. She works but currently cannot work full-time due to her health. She is finally free from an abusive marriage because her husband recently died of alcoholism. So she is a survivor and savvy but at a loss for how to navigate the health care system without being able to read. Martha was able to accept her back as a patient due to her health status, her low literacy, and her precarious employment status.
She is one of a handful of other patients who registered for ACA insurance and have returned to us for help. These patients are, of course, low-income. Most have never had health insurance. Many do not speak English and some are illiterate in all languages. There are so many new terms. What is a co-pay? What is a premium? How do you make an appointment? How can you get a refill on a prescription? Everybody finds health insurance to be filled with too much paperwork and an often confusing list of rules.
Lack of proficiency in English or illiteracy has proved to be a major barrier to becoming a successful consumer of health insurance. We must give credit to the ACA Marketplace, as it is possible to speak to people in a wide variety of languages. Once insured, most written information arrives in English. So much junk mail every day makes it hard to differentiate what is important and what is not. For those illiterate in all languages, it is like wearing a blindfold. What does a monthly premium bill look like? How to read the different and tiny phone numbers on the back of the insurance card? So, while the ACA enrollment process is not simple, it is nothing compared to actually figuring out how to use insurance once you buy it.
Another factor that impacts our clients is that Virginia did not expand Medicaid. For our clinic, this means that people who are below 100% of the Federal Poverty Level are too poor to buy insurance in the Marketplace or ACA health exchange.
The majority of our patients who were able to enroll in a silver plan were also able to qualify for a significant subsidy and enroll in an affordable plan with good benefits. Unfortunately, some of our patients were attracted to the lowest cost plans. While the monthly premium is less expensive, they were unable to afford the high co-pays for appointments and medications. For people who may have never had health insurance, it can be difficult to understand the actual total cost of a high deductible plan. A few of these people have multiple chronic illnesses and require several daily medications. Over time, they stopped going to the doctor and refilling their prescriptions. Sometimes they even stopped making their monthly payments and were terminated by the insurance company. We accepted a few of these patients back, as it was apparent that their without their medications they were putting their lives at risk. We plan to help them re-enroll after the November open enrollment period, in a plan that, hopefully, will work for them.
Some patients lost their insurance when their financial circumstances changed and they were no longer able to make the monthly payments. Most of our patients are living paycheck to paycheck. Many have jobs where the hours can vary greatly from week to week. Their insurance costs are based on income from the previous year. There is a system for reporting changes in circumstances to the Marketplace which, while it can sometimes result in adjusted premiums, is a process that has been too complicated for many of our patients.
In no way do these comments mean that we feel ACA has been a failure. We are a very small clinic and we believe and hope that the majority of patients who were able to purchase insurance have had a good experience. We are no longer in contact with them and do not know their stories. We fully support efforts of those in government to develop programs to allow more people access to high quality medical care. If anyone were to ask how the "ACA failures" might be eliminated, it seems that having a navigator to help learn the ropes of using insurance could have made a difference.
For more information please contact:
Alexis Vanderhye, Director of Foundation Relations
Arlington Free Clinic
2921 11th Street South, Arlington, VA 22204
(703) 979-1425 x 112 firstname.lastname@example.org
Martha Ware, RN, Women's Health Director
Arlington Free Clinic
(703) 979-1425 x 128