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.

• 2010 Early Deliverables:  New high-risk pool; some immediate consumer protections and insurance reforms; premium rate disclosures and oversight;
• Major Coverage Reforms in 2013 or 2014:  Health Insurance Exchanges create marketplace for insurance under new reforms that prohibit denial or pricing based on health status; premium assistance and out-of-pocket caps, Medicaid expansion for poorest; individual and employer responsibility with exemptions for small firms and financial hardship; 
• Improved Medicare coverage for prescription drugs and preventive care
• Both bills fully paid for through budget savings and revenue increases:  both reduce federal deficit by more than $100 billion in the first 10 years, and continue to reduce it in the second decade.

Key Differences to Negotiate:

• Financing:  House progressive income taxes versus Senate excise taxes on high-cost health benefits.
• Affordability: House much better for low-income premiums and all incomes on cost-share and benefits; Senate premiums better for moderate-income.  Obvious solution = best of both bills, but where will the money come from?
• Exchanges and Insurance Regulation:  House bill tighter oversight, more consumer-friendly regulation of the insurance industry, Health Insurance Exchange greater negotiation power.
• Abortion:  Both bills prohibit direct federal support or subsidy for abortion coverage.  Issue is whether Exchanges can sell coverage that includes abortion as an “add-on” paid for by the consumer.
• Public Option:  House has a moderately weak model and Senate has none, though would have OPM contract with insurers to offer minimum of 2 plans that meet “qualified health plan” standards and at least one of these must be non-profit.
• Employer Responsibility:  House includes a “pay or play” provision, Senate charges employers penalties only if their employees actually access subsidized coverage.
• Undocumented immigrants:  Senate bill prohibits undocumented from buying insurance through the exchange, even with their own funds.  House does not and Congressional Hispanic Caucus opposes Senate language.
• Closing the Medicare Part D “doughnut hole”:  How to pay for this is the issue.

For more on the differences, see the Community Catalyst blog and the House Tri-Committee staff comparison of key differences

Working Age Texans Most Likely To Be Uninsured

In Texas, 32 percent of adults ages 19 to 64 are uninsured compared to 19 percent of children.  It’s a bit surprising that working-age adults in Texas are so much more likely to be uninsured than children, since parents (and not children) often have insurance provided with their job.

But if you look at how children and working age adults get coverage, you see that kids fare much better because we’ve created a safety net with Medicaid and CHIP that provides access to affordable coverage for children in low-income families.  In Texas today, most of the parents whose kids get Medicaid do not qualify, and poor adults without children do not qualify at all. Only adults who are elderly, fully disabled, pregnant women, and a small handful of parents with almost no income can get Medicaid today.  The income-eligibility level for parents—$308 per month for a working parent with two children—has not been increased by the Texas Legislature since 1985.  Parents working just 10 hours a week at minimum wage will earn too much too qualify for Medicaid (but far too little to afford private health insurance).

Expanding Medicaid eligibility to everyone who is living in or near the poverty as proposed in national health reform bills will dramatically increase access to affordable coverage for low-income Texans and make roughly a million low-income uninsured adults in Texas eligible for Medicaid.

The Foundation also updated its interactive side-by-side health reform comparison tool to reflect changes to the Senate Health, Education, Labor and Pensions Committee proposal.  The online tool allows users to compare any of 11 different plans, including the House Tri-Committee legislation and the Senate Finance Committee policy options.

“…[F]rom New Deal-era calls for government-subsidized health coverage to the creation of Medicare and Medicaid in the 1960s and the failed attempt at universal coverage under President Clinton in the 1990s, the history of past efforts offers lessons for policymakers contemplating how to achieve comprehensive health reform.”

Follow this link to read National Health Insurance — A Brief History of Health Reform Efforts in the United States.