His throat and neck reddened and raw from seven weeks of radiation for stage 4 squamous cell carcinoma of the throat and jaw, Paul M. Popadak faces medical bills that have topped $100,000 since his October 2013 diagnosis. To date, his insurance has paid just $2,739.04.
On Jan.1, the rollout of "Obamacare" presented a new opportunity for Popadak, 56, to access affordable care. He went online to healthcare.gov to replace his existing insurance with a plan bought through the Virginia marketplace, also known as the state exchange. The new plans include not only a baseline of "essential health benefits," such as free contraception for women, but also prohibit discrimination against those with pre-existing conditions. (See sidebar.) Through a series of federal subsidies and tax credits based on household income and the number of dependents, a plan's annual premium costs are limited to 9.5 percent of a consumer's income.
"It wasn't easy. You have to really want it and you have to have a good attitude," Popadak said of the patience and persistence necessary to navigate the glitch-plagued system. "The system's not perfect, but 30 years from now we'll have the best system in the world," he added.
Popadak, a self-employed sound engineer and Hampton resident, is among 102,815 Virginians who have enrolled through the state marketplace that took effect with the Affordable Care Act on Jan. 1, 2014. He's typical of those who qualify: people who've lost employer-based insurance along with their jobs, the self-employed for whom individual insurance was previously prohibitive, the long-time uninsured, and the working poor.
Who can use marketplace
The marketplace is intended to serve those who make too much to qualify for Medicaid, but not enough to purchase private insurance. In all, 251,566 Virginians have been found eligible to enroll in a marketplace plan — deadline March 31 for 2014 coverage — according to the U.S. Dept. of Health and Human Services in a report released Tuesday. Its numbers reflect enrollment through February.
In Virginia, where the legislature is locked in a partisan divide over the expansion of Medicaid, there is still a "coverage gap" for another 375,000 state residents who make too much to receive existing Medicaid but not enough to purchase a marketplace plan. At Southeast Virginia Health System (formerly PICH), application counselor Sylvia Whitaker reports that 60 percent of her clientele falls into the coverage gap created by the state's non-expansion of Medicaid.
Of the newly enrolled through Virginia's "federally facilitated" marketplace, 56 percent are women, and more than one-quarter fall into the prized young demographic, ages 18 to 34. The greatest number, 75,000, have opted for the "silver" plan — "it offers the best fit in terms of premium and services rendered," according to TFA Benefits broker Linda Palmer — another 16,450 for the lower-cost "bronze," and 11,300 for the higher-tier "gold." Eighty percent of Virginia's enrollees are receiving some federal subsidy for their premiums.
Palmer, a 30-year-veteran of the health insurance industry, has sold approximately 60 or 70 marketplace health plans. "It's primarily people whose employers didn't offer coverage and a few that the coverage was just so expensive. They're just elated," she said, describing how many haven't been able to afford a physical for years and present with extreme anxiety in her office. "I've had people cry in my arms. The reward is the relief of the people's emotions. I didn't expect it at all," she said. "They're mesmerized, they really are. There's a feeling of jubilation."
Palmer's clients are not confined to employees — she has also signed up small business owners who found individual marketplace plans more affordable for both themselves and their employees.
By mid-February, more than 20,450 Virginians had also enrolled in standalone dental plans offered through the exchange. That's because they're finding that the affordability of their health coverage allows them the leeway to purchase the dental insurance, said Palmer.
What coverage means
Aside from the difficulties encountered in the actual sign-up process, the Peninsula residents who've enrolled expressed gratitude and relief at having effective coverage.
"We almost missed getting coverage," said A.J. Orlikoff, a 22-year-old Newport News resident and Old Dominion University senior, recounting the difficulties he and his mother encountered in applying online. At one point, the system kicked them off and they had to reset everything and re-enter their information in order to apply. Then it took another hour on the phone. Now, he's delighted after being uninsured since he aged out of the Medicaid program at 18. "I can go to the doctor now," he said, citing a chronic skin condition for which he had been prescribed a cream costing $400.
"Obviously, that was something I couldn't do," he said. Their silver plan leaves them liable for 6 percent of their medical costs above a modest monthly premium of less than $100. "It really is changing our lives. It helps having the security," Orlikoff said, while noting that his social media posts about it have generated "snarky" responses. "I almost feel like there's a social stigma about it," he added.
Similarly, Williamsburg resident Katherine Warrick, 26, who bought a "very reasonable multistate silver plan" that covers her while she has a short-term teaching job in Texas, has found a lot of misunderstandings about the ACA among her contemporaries. "It really is amazing, they think they have to pay these whopping amounts," she said. When she finds permanent employment, she hopes to be the beneficiary of employer-sponsored insurance. In the interim, she's happy with her new plan. "I definitely needed it for this transition," she said.
As a full-time health care provider, Chanel Jackson, 32, doesn't receive insurance from her employer. The Newport News resident had been without coverage for two years, during which time she didn't go to the doctor. She signed up at the earliest opportunity and for $30 a month and a co-pay of $5 for primary care, $15 for a specialist, Jackson has been getting all her annual preventative exams. "Everything's been fine," she said.
Since his new coverage went into effect on Feb. 1, a silver plan through Anthem HealthKeepers, Popadak has received aggressive chemotherapy and radiation treatments on a daily basis. It costs him $89.28 a month compared to the $230 he was paying previously. He recently paid the oncologist $650, which meets his out-of-pocket annual maximum. His liquid nutrition supplies, the pump, the instructions on how to use it, all came free.
His bills are no longer denied, though last weekend he did have to wait for a needed blood transfusion and go to a facility farther from his home when the closest one wouldn't accept his new insurance. Overall, he's delighted.
"I had a piece of plastic that opened a door," he said, flashing his old insurance card. "Now I have health insurance."
Want to sign up?
What: To enroll in health insurance through the marketplace, go to http://www.healthcare.gov or http://www.enroll-virginia.com.
When: Deadline for 2014 enrollment to meet the ACA individual mandate is March 31, 2014.
Information: For navigator help, call Heather R. Parsons, 757-275-0125; 888-392-5132 firstname.lastname@example.org 8:30 a.m. to 5 p.m.
• For certified application counselor help, call the Southeastern Virginia Health System, 757-380-8709, to find the location nearest you.
• For help, or to apply by phone, call 1-800-318-2596.
• Paper applications are available at Department of Social Services offices, from Heather Parsons, and from Southeastern Virginia Health System clinics throughout the region. They can also be printed from online.Copyright © 2014, The Baltimore Sun