Health Insurance? Pittsburgh's Got Ya Covered!

by Alex Carter

Health insurance has always been a necessity for Susan and Mark. Their daughter, Catherine, has struggled with debilitating mental health conditions throughout her life, leaving her unable to work and dependent on multiple expensive medications. The family has always received quality coverage from Mark’s employer. But this year, Catherine will turn 26, making her ineligible to be covered under her parents’ insurance. The family is distraught. Without insurance, Catherine will never be able to afford her prescriptions or psychiatric services. 

Although Catherine’s low income qualifies her for Medicaid (low cost government-sponsored insurance), her condition requires specialty drugs and appointments that would not be covered on such a plan. Without a job, she would have no chance of receiving employer-based coverage. And even though her mental health conditions are restricting, she does not qualify for Social Security Disability and the Medicare coverage accompanying it. So where are they to turn for insurance now?  

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The Patient Protection and Affordable Care Act (ACA, or “Obamacare”), signed into law in 2010, represents the most comprehensive reform of American health care since the establishment of Medicare and Medicaid in 1965. Intended to expand coverage to millions of uninsured Americans while also curbing the government’s health care expenditures, the law is vast in scope and pertains to health care providers, insurers and recipients alike. Some reforms have been unanimously welcomed – new consumer protections, easier ways to compare coverage options and greater accountability for insurance companies – while other changes, such as heightened demands from state governments and private employers, have been met with great resistance.  

While the long-term economic impacts of these fresh reforms are still unclear, the effect on consumers is concrete: Since 2009, 16.4 million previously uninsured Americans have obtained coverage. The Marketplace, launched in 2013, has brought the total uninsured rate down from nearly 20 percent to about 13 percent. And lastly, of the nearly 12 million people who have enrolled in insurance through the Marketplace, 87 percent have received financial assistance in the form of tax subsidies.  Without attempting to summarize this nearly 20,000 page bill, let’s focus on the ramifications of the ACA for us Pittsburghers, especially young adults who are uninsured or underinsured. 

Most of the ACA’s reforms apply to all insurance companies and consumers, but a few aspects do differ state-by-state. One example is the establishment of online Marketplaces, which are websites that consumers can use to compare insurance options. Each state has the choice of using the Federal Marketplace, a state-based Marketplace, or a combination of both, which could cater to the unique needs of its population. A second major decision left to the states is Medicaid expansion. Medicaid is a federal and state government funded health insurance program for predominantly low-income or disabled citizens. Every state has a unique Medicaid program varying in its individual qualification standards, benefits and modes of compensating physicians. The ACA originally required states to expand their Medicaid programs to include any adults with incomes below 138 percent of the federal poverty line (FPL), but this statute was struck down in a 2012 Supreme Court challenge. Now, each state can decide if it wants expanded Medicaid, and if so, how to best go about expansion. 

So where does Pennsylvania fit in with these issues? Under the direction of former Governor Tom Corbett, Pennsylvania chose to utilize the federal Marketplace while rejecting traditional Medicaid expansion in favor of a more privatized system. While Corbett’s model did extend coverage to more citizens, many heavily criticized it for being too complex and inefficient for ordinary residents to navigate. When current Governor Tom Wolf took office, he immediately embraced traditional expansion. Now any citizen below 138 percent of the FPL qualifies for extremely low cost medical assistance, regardless of their health status. What’s more, for Pennsylvanians whose incomes fall between 138 percent and 400 percent of the FPL, significant subsidies are available on insurance purchased through the Marketplace. 

Understandably, many Pennsylvanians are not fully aware of their rights and opportunities as consumers, given the long and complicated history on the topic. Fortunately, free resources are available to help navigate the system right here in our city. One such notable resource is the Consumer Health Coalition (CHC). 

For nearly twenty years, the CHC has been providing free enrollment services to the greater Pittsburgh community in its mission to “advance health and enhance access to quality affordable health care.” The organization has five health care Navigators on staff, each of whom is certified to complete insurance applications on behalf of consumers. In 2014, CHC staff completed 961 new applications, provided health care counseling and education to 1,384 people and educated over 6,000 Pittsburghers in community outreach events. 

Clients at the CHC come from all backgrounds – immigrants, homeless, families and both ill and healthy individuals, all of whom benefit from the CHC’s services. Whether it is over the phone or in person, counselors can help consumers determine their likelihood of eligibility and obtain coverage for underinsured children and families.  If a client is particularly disadvantaged, counselors will also connect them with other nonprofit organizations that can provide resources such as food, housing or emergency medical care. Assistance is always available for Pittsburghers through the CHC – all one has to do is reach out. 

For many students and young working adults, health considerations often take the backseat against more pressing issues like rent payments and school tuitions. To forgo insurance, however, is a risky gamble, especially when one considers that medical bills are the most common cause of personal bankruptcies in the U.S. For young adults on tight budgets, numerous options are available: coverage under parents’ plans until age 26, coverage from universities’ plans and “catastrophic” health plans from the Marketplace and Medicaid, just to name a few. 

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“When one is covered, it’s easy to take insurance for granted, but as Catherine’s family can attest, lost coverage comes with lost peace of mind,” said Leslie Bachurski, CHC’s Director of Consumer Navigation. Fortunately, with the help of her parents, CHC services and the recent ACA reforms, Catherine was able to avoid a financially ruinous coverage gap. After weighing the pros and cons of dozens of options on the federal Marketplace, the family selected a comprehensive plan that covered Catherine’s prescriptions and accepted her doctors of choice. 

As the 2016 Presidential election heats up, health care will once again become a national topic of debate. Candidates from both parties will be expected to endorse the recent reforms or propose new ideas, while some may even call for a complete repeal of the ACA. The future of the American health care system is certainly uncertain. However, we can take solace in the fact that organizations like the Consumer Health Coalition are prepared to help Pittsburghers exercise their right to quality, affordable health care.