The Wall Street Journal today published an op-ed from one of the self-proclaimed “losers” of healthcare reform — a woman who has, against the odds, survived stage 4 gallbladder cancer.
Edie Littlefield Sundby writes that her insurer, United Healthcare, has paid some $1.2 million to help her stay alive, without hassling her about any of the recommendations made by her medical team.
But now that United has pulled out of the individual insurance market in California, she’s in need of a new plan. Sundby writes that she spent four weeks researching plans on California’s state-run health insurance exchange, Covered California, and talking to navigators, insurance companies, medical providers and an insurance broker to find a similar plan.
“You would think it would be simple to find a health-exchange plan that allows me, living in San Diego, to continue to see my primary oncologist at Stanford University and my primary care doctors at the University of California, San Diego. Not so. UCSD has agreed to accept only one Covered California plan—a very restrictive Anthem EPO Plan. EPO stands for exclusive provider organization, which means the plan has a small network of doctors and facilities and no out-of-network coverage (as in a preferred-provider organization plan) except for emergencies. Stanford accepts an Anthem PPO plan but it is not available for purchase in San Diego (only Anthem HMO and EPO plans are available in San Diego).”
So, she writes, choosing a more affordable health-exchange plan would require her to also choose between the teams of doctors that have kept her alive. Or, she could go with an outside insurance plan that would let her keep her providers at the cost of 40 to 50 percent higher premiums.
Sundby finishes it off with this zinger:
“For a cancer patient, medical coverage is a matter of life and death. Take away people’s ability to control their medical-coverage choices and they may die. I guess that’s a highly effective way to control medical costs. Perhaps that’s the point.”
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
Liberal blog ThinkProgress was quick to fire back, saying Sundby shouldn’t blame reform for her troubles but rather business. United Healthcare has struggled to compete in California’s individual healthcare market for years and was worried that the first wave exchange enrollees would be sicker population:
“Sundby is losing her coverage and her doctors because of a business decision her insurer made within the competitive dynamics of California’s health care market. She’ll now have to enroll in a new plan that offers tighter networks of providers as a way to control health care costs and offer lower premiums. Eleven insurers are participating in Covered California and for the first time they won’t be able to deny coverage to Sundby or any other cancer patients.”
Read the letter (and the nearly 1,200 comments) here.
