<html><body><div style="color:#000; background-color:#fff; font-family:times new roman, new york, times, serif;font-size:12pt">http://www.nytimes.com/2012/04/05/opinion/down-the-insurance-rabbit-hole.html?ref=opinion<br><br>
<div class="timestamp">April 4, 2012</div>
<h1>Down the Insurance Rabbit Hole</h1>
<span itemprop="creator" itemscope="" itemtype="http://schema.org/Person"><h6 itemprop="name" class="byline">By ANDREA LOUISE CAMPBELL</h6></span>
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Cambridge, Mass. </div>
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ON the second day of oral arguments over the Affordable Care Act,
Solicitor General Donald B. Verrilli Jr., trying to explain what sets
health care apart, told the <a href="http://topics.nytimes.com/top/reference/timestopics/organizations/s/supreme_court/index.html?inline=nyt-org" title="More articles about the U.S. Supreme Court." class="meta-org">Supreme Court</a>,
“This is a market in which you may be healthy one day and you may be a
very unhealthy participant in that market the next day.” Justice <a href="http://topics.nytimes.com/top/reference/timestopics/people/s/antonin_scalia/index.html?inline=nyt-per" title="More articles about Antonin Scalia." class="meta-per">Antonin Scalia</a>
subsequently expressed skepticism about forcing the young to buy
insurance: “When they think they have a substantial risk of incurring
high medical bills, they’ll buy insurance, like the rest of us.” </div>
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May the justices please meet my sister-in-law. On Feb. 8, she was a
healthy 32-year-old, who was seven and a half months pregnant with her
first baby. On Feb. 9, she was a quadriplegic, paralyzed from the chest
down by a car accident that damaged her spine. Miraculously, the baby,
born by emergency <a href="http://health.nytimes.com/health/guides/surgery/c-section/overview.html?inline=nyt-classifier" title="In-depth reference and news articles about C-section." class="meta-classifier">C-section</a>, is healthy. </div>
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Were the Obama health care reforms already in place, my brother and
sister-in-law’s situation — insurance-wise and financially — would be
far less dire. My brother’s small employer — he is the manager of a
metal-fabrication shop — does not offer <a href="http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/health_insurance_and_managed_care/index.html?inline=nyt-classifier" title="Recent and archival health news about health insurance and managed care." class="meta-classifier">health insurance</a>,
which was too expensive for them to buy on their own. Fortunately, my
sister-in-law had enrolled in the Access for Infants and Mothers
program, California’s insurance plan for middle-income pregnant women.
AIM coverage extends 60 days postpartum and paid for her stay in
intensive care and early rehabilitation. </div>
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But when the 60 days is up next week, the family will fall through the
welfare medicine rabbit hole. As a scholar of social policy at M.I.T., I
teach students how the system works. Now I am learning, in real time.
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For health coverage, the baby fares best. He is insured through Healthy Families, California’s version of the <a href="http://topics.nytimes.com/top/reference/timestopics/subjects/s/state_childrens_health_insurance_program_schip/index.html?inline=nyt-classifier" title="More articles about the State Children's Health Insurance Program (S-CHIP)." class="meta-classifier">Children’s Health Insurance Program</a>, the federal-state plan for lower-income children ineligible for <a href="http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/medicaid/index.html?inline=nyt-classifier" title="Recent and archival health news about Medicaid." class="meta-classifier">Medicaid</a>
whose families cannot afford private insurance. California is
relatively generous, with eligibility extending up to 250 percent of the
federal poverty level of $19,090 for a family of three; 27 states have
lower limits. </div>
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When the AIM coverage expires, my sister-in-law will be covered by
Medi-Cal, California’s version of Medicaid, because she is disabled and
has limited income. But because my brother works, they are subject to
cost-sharing: they pay the first $1,100 of her health costs each month.
Paying $1,100 leaves them with a monthly income of just 133 percent of
the federal poverty level. If my brother makes more money, their share
of the cost increases. </div>
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They must also meet the Medi-Cal asset test: beyond their house and one
vehicle, they can hold $3,150 in total assets, a limit last adjusted in
1989. They cannot save for retirement (retirement plans are not exempt
from the asset test in California, as they are in some states). They
cannot save for college (California is not among the states that have
exempted 529 college savings plans from their asset tests). They cannot
establish an emergency fund. Family members like me cannot give them
financial help, at least not officially. If either of them receives an
inheritance, it will go to Medi-Cal. Medi-Cal services that my
sister-in-law uses after age 55 will be added to a tab that she will
rack up over the rest of her life. When she and my brother die, the
state will put a lien on their estate; their child may inherit nothing.
Even my brother’s hobby runs afoul of the asset test: he enjoys working
on old cars, which he can no longer keep. </div>
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These are the limitations under which 7.5 million Medi-Cal recipients
live. Nationwide, more than 50 million people are covered by their
states’ version of Medicaid. Some states are more lenient in their
income and asset tests, others less so. Nowhere is life in these
programs a picnic. </div>
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That said, Medicaid is an important safety net for the poor, and the
Obama reform would expand the program to cover all Americans under 133
percent of the poverty level (currently one has to be both poor and
categorically eligible — a child or a pregnant woman, for example). But
for the middle class who are thrust into Medicaid by circumstance, the
program’s strictures are truly life-altering. My brother and
sister-in-law desperately wanted to buy insurance and now wonder how to
escape Medi-Cal’s forced penury. My sister-in-law will qualify for <a href="http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/medicare/index.html?inline=nyt-classifier" title="Recent and archival health news about Medicare." class="meta-classifier">Medicare</a> after the mandatory 24-month waiting period for disabled people, but Medi-Cal will be the secondary payer. </div>
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Their best hope is the survival of the Obama reform. Perhaps my brother
can get a job that offers health insurance for the family, but without
the reform’s protections, like the prohibition on denying coverage for
pre-existing conditions, removal of annual and lifetime insurance caps,
and reinsurance for large claims, there is no guarantee that they could
obtain insurance. More likely, they would buy insurance on a health
exchange. Here in Massachusetts, where such an exchange is in place,
they could have purchased a plan with an affordable premium (at their
income level, the monthly premiums range from $39 to $91 per adult). And
these money and insurance issues would not have added to the other
stresses in their profoundly changed lives. </div>
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Instead, their financial future is shattered. Family and friends are
raising money to buy a wheelchair van and to renovate their home for
accessibility. The generosity of the local community is stunning. One
incident in particular struck me to the core. A woman from a small
community nearby had something for us. A <a href="http://health.nytimes.com/health/guides/disease/cancer/overview.html?inline=nyt-classifier" title="In-depth reference and news articles about Cancer." class="meta-classifier">cancer</a>
survivor, she had decided to “give back” by placing donation cans in
stores around town. She had finished her drive and consolidated the
money. The small coffee can she handed over to me and my sister-in-law
had a slit in the lid and was decorated with pink felt and ribbons, now a
little smudged from handling. Inside were several hundred dollars in
small bills. We burst into tears. This is social policy in the richest
nation in the history of the world. </div>
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<div><a href="http://web.mit.edu/polisci/people/faculty/andrea-campbell.shtml">Andrea Louise Campbell</a> is an associate professor of political science at the Massachusetts Institute of Technology.</div> </div>
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