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Sick Americans find solace in health reform’s pre-existing conditions guarantee

November 13, 2013 at 12:00 AM EST
After Martha Monsson was diagnosed with cancer, her husband lost his job and their health care. In our series of personal stories about the effects of health reform, Monsson voices support for the law's guarantee of care for those with pre-existing conditions. Mary Agnes Carey of Kaiser Health News joins Judy Woodruff for more.
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TRANSCRIPT

 GWEN IFILL: That brings us to another chapter in our series featuring reactions to the Affordable Care Act, as more people become aware of the details.

Yesterday, we aired the story of a Washington, D.C., lawyer who was angry that her current insurance policy had been canceled.

Tonight, we hear from a Colorado woman who was diagnosed with cancer just before her husband lost his job and his health care plan.

Here’s some of what she told us:

MARTHA MONSSON, cancer sufferer: I am Martha Monsson. I’m 59 years old.

I was diagnosed when I was 54, January of 2008, with multiple myeloma, which is a bone marrow cancer. The treatments for that mainly are chemotherapy. What the chemo is for, essentially, is to reduce the number of cancer cells.

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This treatment is lifesaving. I would have died probably in February 2008 without it. When I was first diagnosed, my husband was the county attorney in Morgan County. And we had insurance through them. But his job was eliminated.

So, since then, he has been doing contract work, which has kept income coming in, but, for insurance, all we have had is through COBRA. That expires at the end of February. If he doesn’t have another job by the end of February, we would have to apply for private insurance. We would get turned down because of my preexisting condition.

Even if they were going to take me because of the preexisting condition, it would be hugely expensive. The affordable health care act means that I have a chance, that I don’t have to stop treatment once the insurance runs out.

MAN: We will be able to get something.

MARTHA MONSSON: Yes, yes.

MAN: But we will have to pay more.

MARTHA MONSSON: It’s huge, and I think particularly to my family, because they wouldn’t like to have to pull the plug.

This law is very much a game-changer for us. I am hoping that, in January, when this comes into effect, that I will not have to worry about the insurance we have now ending in February, that I will be able to keep getting treatment.

There’s methadone, which is a pain pill for my spinal degeneration.

When I was first diagnosed — well, obviously, the first reaction was to wish it hadn’t happened. But the second reaction was to wish it had happened someplace civilized, like France, or Canada, where you get health care kind of as a matter of course, and it isn’t as expensive as it is here.

The problem, I think, is, a lot of people think that, if they’re healthy, they’re going to say healthy forever. And even though I had insurance, I thought I was going to stay healthy forever. People who oppose the affordable health care act very definitely don’t have the bigger picture. They don’t see that it can happen to them, and either they don’t care or they don’t see what it does to other people.

People are one diagnosis away. And they don’t realize it, to a large degree, but it’s very true. What I tell people who oppose the Affordable Care Act is, fine. If you want to abolish it, you can pay my medical bills. That would be wonderful. I — give me a mailing address, and I will forward my bills to you.

JUDY WOODRUFF: So, Mary Agnes Carey of Kaiser Health News is still with us to help put Ms. Monsson’s story in perspective.

And I want to say, our hearts go out to her.

MARY AGNES CAREY: Absolutely.

JUDY WOODRUFF: And we appreciate her talking with us.

So, tell us, why is the Affordable Care Act a welcome thing for someone like her?

MARY AGNES CAREY: Because, in the individual market before the Affordable Care Act, she would most likely be rejected for coverage, because she has cancer, because her medical expenses are so high.

This is a problem that about a quarter — about 20 percent or so of people in the individual market applying for coverage get these rejections based on medical status. That is no longer allowed with the Affordable Care Act. You can’t be rejected because of a medical condition.

JUDY WOODRUFF: But this is a story that hasn’t been told, I think, in many respects. People are aware of it, I think, but we don’t hear about it that often.

MARY AGNES CAREY: I think it’s part of — she put it out very well. We’re all one diagnosis away from this sort of thing, and unless you have experienced it directly in your family or personally, you may not think about the hardship that comes from this kind of diagnosis, and the fact that you can exhaust your limits pretty quickly on coverage, and if you had to go out and buy it yourself, you can’t get it.

JUDY WOODRUFF: So, literally, Mary Agnes, what would someone’s options be in her situation if it had not been for the Affordable Care Act? What could she have done?

MARY AGNES CAREY: She talked about COBRA, which is the extension of coverage you can buy from an employer. Once that ran out, she could go to an insurance agent to try to buy coverage in the individual market again. She might have been denied. It would be very, very expensive.

She might have gone into something called a high-risk pool, which is — they’re state-run in many cases, and they are there to help handle the high risk. But that would also be an extremely expensive option for her. Now, depending on their family income, they may or may not have qualified for Medicaid. But, again, all of these are really tough choices.

JUDY WOODRUFF: And she mentioned her husband’s situation. So, some of this — so much depends of this on where you live, your spouse or your family’s situation.

MARY AGNES CAREY: Right.

JUDY WOODRUFF: I mean, it’s not — it’s not a cookie-cutter, one-size-fits-all.

MARY AGNES CAREY: No, absolutely not. And it’s very much geared to your particular circumstances, your medical — that was all the medical underwriting that is going away with the Affordable Care Act.

JUDY WOODRUFF: So, talk — talk, Mary Agnes, about — about how big a part of the entire market of people, number of people who are looking for coverage are people like Ms. Monsson.

MARY AGNES CAREY: Again, you have about 14 million people on the individual market. That represents about 5 percent of everyone who is insured.

And of that 14 million, of those who apply, about 20 percent would be rejected based on their health care status. So, it’s a small group, but a very powerful group because of the damage that this does if you don’t have health coverage and what it does for your medical treatment, what it does for your personal finances.

And what’s interesting to me is, this provision, even people who dislike the Affordable Care Act, they like the idea that someone cannot be rejected on the basis of a medical condition for health insurance. So, it’s a provision of the law that polls very well.

JUDY WOODRUFF: So, is it literally the case that you are accepted under the Affordable Care Act no matter what your health condition is?

MARY AGNES CAREY: Right.

JUDY WOODRUFF: No matter how far along an illness may be?

MARY AGNES CAREY: That’s correct.

They can have some adjustments based on your age or whether or not you smoke or where you live in the country, but, generally, are you allowed to have coverage under the Affordable Care Act. And an important think to note, as we talked about last night, this whole sticker shock idea, this is one of the most — this is one of the provisions that is driving up the cost for health premiums.

It’s an expensive provision, but this plus the essential health benefits are two of those factors behind all the sticker shock we’re hearing about.

JUDY WOODRUFF: Now, part of the larger picture here, though, is that we know that for this new law to work, not everyone can have — can be sick. There have to be healthy people signing up, too.

MARY AGNES CAREY: Right.

JUDY WOODRUFF: Explain how that works and how that balance works in the law.

MARY AGNES CAREY: It’s a balance. It’s a balance of risk.

The healthier individuals get into the same risk pool as the sicker individuals and help balance the risk out over time. That’s why you need — someone like Martha, who is really sick, who may or may not have problems signing up with healthcare.gov, they’re going to hang in there to get coverage.

The folks that they also need to come into the risk pool are people who currently have coverage and are healthier, may have had fewer medical problems, but stay in health coverage to help balance that risk.

JUDY WOODRUFF: But for the — of course, for those who are healthy, it’s harder to — as you have just been saying, it’s harder for them to understand why — why it is something for them to seriously consider signing up.

MARY AGNES CAREY: Right.

And if they have done well in the individual market as a healthier person, their premiums may increase. That was the woman we talked about last night. Her premiums are increasing. She kept saying she hadn’t had some — she had a few medical issues this year, but overall had been a healthy person.

If you have had lower premiums in the individual market, and you have been healthier, you may pay more under the Affordable Care Act.

JUDY WOODRUFF: So, Mary Agnes, just pulling back again, and thinking about what we talked about a few minutes ago about what we learned today about the enrollment numbers, how — as the insurance companies watch all this that is happening with the enrollment numbers, with the stories that we’re telling of individuals like the woman we heard from last night, like Ms. Monsson, how does it affect the behavior of these companies and their ability to take on new insurance policies?

MARY AGNES CAREY: Well, they have based their premiums for 2014, when the exchanges begin and the Medicaid expansion begins and so on, based on an assumption that sick people would come in and healthy people would come in, that people currently in plans that are not deemed to be up to snuff with the Affordable Care Act, that they will transition to new plans.

So, all this conversation we heard about, for example, letting people stay on their current health insurance plans, that is going to undermine the risk pool and could affect premiums in 2015 and beyond. So, insurers are very closely watching this.

JUDY WOODRUFF: As are we all, and as I know you are.

MARY AGNES CAREY: Absolutely.

JUDY WOODRUFF: Mary Agnes Carey, thank you very much.

MARY AGNES CAREY: Sure. Thank you.

Editor’s note: Martha Monsson died on Feb. 20, 2014. Her husband George told us “Our gallant, wonderful, talented lady finally lost her fight at 10:18 this morning.”