Our Current Health Care System Fails Newly-Disabled Texans

The month after his open heart surgery, Mario applied for Social Security Disability benefits.  Like many workers who become disabled as adults, Mario was certified for both SSI (income related) and SSDI (work history related) disability cash benefits.  His SSI started right away, which automatically qualified him for Medicaid, too.  This Medicaid coverage retroactively took care of his surgery bills.  By federal law, work-related SSDI benefits do not begin until 5 months after you are found eligible.  Very often, a worker’s SSDI benefits—based on their past earnings—are higher than the maximum income allowed for SSI, and this was the case for Mario.  So, when his SSDI cash benefits began, he lost his SSI and Medicaid (health coverage for very low-income citizens).  Then, he began waiting out the federally-required 24-month period before Medicare health coverage for people over age 65 and adults who become disabled) starts for SSDI beneficiaries.  This left Mario uninsured for two more years as he faced high out-of-pocket costs for follow-up care, making it difficult for him to seek regular treatment with a primary care physician.

I have helped a lot of people to navigate the health care system, and I share what I’ve learned.  We have to make our voices heard.  There are people who have savings, who can draw upon an inheritance to defray medical coasts.  But we need health reform for our children, so they can have health insurance.

While he waited without any health coverage, his health worsened and Mario had to go back to the emergency room several times for care.  Though his hospital qualified him for assistance based on his low income, he was still harassed by collection agencies for the costs of his cardiac care, and had to get help from Legal Services with his creditors.  Only because of help from family members were Mario and his wife able to make their mortgage payments and keep their home.  Mario survived the two years and 5 months it took to get Medicare based on his disability, but over 50,000 Americans with disabilities die every year while waiting out the 24 months before they get their Medicare.

Today, Mario has Medicare, plus help from Texas Medicaid with his Medicare premiums, co-payments and deductibles.  His wife, however, remains uninsured and must contend with chronic arthritis and back injuries without the benefit of insurance.  Once again, they worry about how they will get her the care she needs and keep a roof over their heads at the same time.

How the Current System Fails Newly-Disabled Adults like Mario

• Once an adult worker becomes fully disabled and qualifies for SSDI, they must wait two years and 5 months before Medicare coverage begins.  It is estimated that about 1.5 million newly disabled adults are in this waiting period today, and about one-third are uninsured and at high risk of either going without needed medical care, or incurring substantial medical debts.
• The Texas high-risk pool is their only option for private coverage unless their spouse is covered by an employer group insurance plan.  By definition, to qualify for SSDI, these folks cannot work at all, so very few of the uninsured individuals in the waiting period have adequate income to buy coverage through the pool, which has very high premiums and deductibles.

Top 3 Ways Health Reform Would Help Mario:

1. As a low-income self-employed man, Mario could have afforded good coverage at a fair price, and accessed routine care that might have detected and treated his heart condition before it became severe, and prevented or delayed his disability.
2. After becoming unable to work and losing Medicaid due to his SSDI benefits, Mario would have been able to purchase affordable coverage through the Health Insurance Exchange that could not be denied or priced higher because of his medical condition, and qualify for help with his premiums and out-of-pocket costs.
3. Mario’s wife would also be able to buy good, affordable coverage through the exchange, and get help with her premiums and out-of-pocket costs.  She would not have to defer getting the care she needs, or wait until she is too sick to work to qualify for help.  She could continue to work for a living and still rely on having affordable health care.