Posts Tagged ‘Health Insurance Coverage’

Waiting for 2014: One Family’s Story

Thursday, August 23rd, 2012

When Joshua Lemacks of Richmond, Virginia takes the field for one of his Little League games, the other team may not be overly impressed with his batting average stats, but those who know him realize that he has beaten extreme odds just to be standing on that field with his teammates.  What the other team doesn’t know is that if Joshua and his parents hadn’t batted 1000 in his early years, he wouldn’t be alive today.

Nine years ago, soon after Joshua was born, a fetal cardiologist came into the room with a box of tissues and told his parents that their newborn’s heart defect was 100% fatal. Later, the cardiologist offered them somewhat better odds if Joshua underwent three high-risk surgeries, one right after delivery.  His odds of surviving the first surgery were about 5 percent. Joshua’s parents, Jodi and Mark, opted for the surgeries because they wanted to give their baby the best chance they could.  Even though they were insured, they incurred monumental out of pocket costs.

Today, Joshua has not only beaten those odds, he is thriving. “He’s as healthy as a horse,” Jodi says. He plays baseball and golf and is a very happy child who seems like any other active little boy except for the scar on his chest and the medical bills that have piled up for his family.

Even when Josh is healthy, the family’s medical bills add up. Josh has, effectively, “half a heart,” as Jodi puts it, and with today’s technology, his defect cannot be “fixed.” He needs regular check-ups, but he also needs to see a cardiologist at least once a year and undergo expensive testing.  Also, while he doesn’t get sick more often than other children, normal childhood illnesses hit him harder than they do others because his heart can’t work as effectively.  Jodi estimates their health care expenses to be as much as $17,000 in out-of-pocket costs, including premiums, in good years when Josh is relatively healthy. This is a substantial portion of their family income. Even though it’s comprehensive medical insurance, the premiums and co-payments required to obtain needed medical care are prohibitive.

This affects not only Josh but the whole family. When Josh’s older brother hurt his arm in an accident during a family trip to New Orleans, they debated going to the emergency room for x-rays because of the cost. They did take him – he’s their son, after all – but, just as they feared, they got “nailed with bills” because their plan only covered a fraction of the cost.

“I feel trapped” in this health insurance policy, Jodi says. Even though she has a better, more generous group plan through her job at a national non-profit, Jodi is afraid to move her kids and husband onto it. Why? Because when the family enrolled in their current policy, Joshua hadn’t been born yet. And he hadn’t yet had his diagnosis of hypoplastic left heart syndrome. As a result, the insurance company’s underwriters assigned him the healthiest possible risk category – a “1” in insurance terms. As high as they are, their premiums are set as if Joshua were a “normal,” healthy child.

But that would not be true if they were looking for a new individual policy on the market today. An insurance underwriter would take one look at Josh’s medical history and run in the other direction. If the family obtains a new policy that includes Joshua, they can expect to pay high rates because of Joshua’s illness– as much as $3100 per month in Virginia, their home state. So Jodi is afraid to move him off their current policy and onto her group plan. If she were to lose her job-based insurance for any reason, they almost certainly could never find an affordable new policy for Joshua.

Because of Joshua’s condition, he will inevitably need long-term monitoring and care. His heart problem cannot be “fixed.”  Kids with this problem may develop arrhythmias, may need a pacemaker, and can develop liver disease, among other complications. Because the oldest person with this condition is only in his 30s, no one really knows what the life-expectancy is, but we do know care over their lifetime will be costly.

With the Affordable Care Act comes new hope for Joshua and his parents. Beginning January 1, 2014, insurance companies will no longer be allowed to charge more to cover Joshua because of his heart condition. The family will pay the same premiums as a family without any health problems.

And Jodi is looking forward to the new state-based marketplaces called insurance exchanges, which will, for the first time, offer web-based tools so she can make apples-to-apples comparisons among different health plan options to select a plan that has the doctors and care Joshua needs.

We asked Jodi what it would mean for her to have guaranteed access to policies in which Joshua couldn’t be discriminated against based on his health status, and an exchange where she could compare her options. She responded: “That gives me choices. I also think it will be more competitive. Right now I’m stuck. I don’t like our current policy, but I can’t move Joshua anywhere else. But if I can compare plans on an exchange, maybe there is one out there that covers a bit more of what we need. That would give me the freedom to choose it.”

In addition, because the family’s income is less than 400% of the federal poverty level, they are likely to qualify for the ACA’s tax credits to help defray the cost of their insurance premiums. In addition, health plans will be required to cover a comprehensive set of benefits and limit families’ out-of-pocket costs.

Jodi imagines a future for Joshua under the ACA in which he can embark on a career that matches his skills and passions, secure in the knowledge he can get the health coverage he needs. He won’t have to choose a job just because it offers a good health plan. “He can start out of college…and he’ll have choices,” she says. “He is such an amazing child, and we love him so much. Like any parent, we want the absolute best for him.”

Thanks to the support of the Robert Wood Johnson Foundation, the AHA is proud to be a part of the Georgetown University Health Policy Institute’s “Real Stories, Real Reforms” project.  You can read more profiles of everyday people across the country who will – or have already – benefited from new consumer protections under the Affordable Care Act on the CHIRblog .  This post – about Joshua and his family – marks the first story in the series.  We hope you’ll follow future stories about the impact of the Affordable Care Act.

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Help Us Protect Consumers’ Health Care Rights

Friday, November 18th, 2011

Complex information. Confusing lingo. Details hidden in the fine print. For most Americans, choosing a health care plan is very difficult. As a result, some patients find themselves with insurance plans that do not provide the coverage they need when they need it most.

Luckily, one of the many consumer-friendly provisions in the Affordable Care Act requires that beginning next year health insurance companies must clearly, simply, uniformly detail what each plans covers and how much it costs. This will make choosing health insurance plans easier for millions of Americans.

Unfortunately, special interests in Washington are trying to stop the implementation of this vital tool which would give all Americans the vital information that they need to make the right health care choices for them and their families.

We need to tell the Administration to continue implementing this vital aspect of  health reform. Please take a minute and let your voice be heard!

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National Patient Groups Welcome Supreme Court Announcement to Review Affordable Care Act

Monday, November 14th, 2011

Statement of the American Cancer Society, American Cancer Society Cancer Action Network, American Diabetes Association and American Heart Association

WASHINGTON – November 14, 2011 – The nation’s leading groups representing patients and families living with cancer, diabetes, heart disease or stroke issued the following statement today in response to the announcement that the U.S. Supreme Court will consider the constitutionality of the Affordable Care Act.

The American Cancer Society, American Cancer Society Cancer Action Network, American Diabetes Association and American Heart Association filed as amici curiae in multiple federal courts of appeal in support of the constitutionality of the law.

Following is a statement from the four organizations that filed the amicus brief:

“Our organizations, which represent tens of millions of people across the country who are living with cancer, diabetes, heart disease or stroke, welcome the Court’s announcement and hope that it will uphold the constitutionality of the Affordable Care Act to ensure that patients with life-threatening chronic diseases can access the law’s critical protections.

“Our organizations believe that patient protections, including those that end discrimination in the insurance market against people with pre-existing conditions, rely on the individual responsibility requirement. These provisions significantly improve the health care system for chronic disease patients and their families by expanding access to quality, affordable health care; reducing the cost burden on families; and refocusing the system to emphasize prevention.

“For decades our organizations have worked to expand access to health care nationwide and to boost our nation’s emphasis on disease prevention and management. As any patient knows, chronic disease strikes people without regard for their opinions or political persuasion. We are optimistic that timely review by the nation’s highest court will help to mitigate confusion and allow implementation to continue in a way that supports and strengthens provisions of the law that enable patients with chronic diseases to access quality, affordable health care.”

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New Heart-Healthy Benefits in Medicare

Friday, November 11th, 2011

Medicare just made it easier for those over 65 to live heart-healthy! On Thursday, November 11, the Centers for Medicare and Medicaid Services (CMS) announced that Medicare will offer more free preventative services that aim to help reduce the risk of heart disease and stroke.  These new benefits are in addition to the many free prevention services established under the Affordable Care Act and are crucial to ensure that our seniors will live well into their golden years. 

Specifically, those in Medicare can receive a yearly in-person meeting with a qualifying primary care practitioner to talk about heart disease and stroke prevention, get screened for hypertension, and discuss healthy eating habits. Read more about the new benefit and see if you or a loved one qualifies for the valuable service. 

This new benefit is a part of the Million Hearts initiative that the U.S. Department of Health and Human Services announced in conjunction with CMS and the Centers for Disease Control. The American Heart Association is a proud partner of the Million Hearts initiative and supports its goal of preventing a million heart attacks and strokes by 2017. To find out more information, visit the Million Hearts website

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American Heart Association CEO Nancy Brown Supports Efforts to Ensure Health Coverage for Children with Pre-Existing Conditions

Friday, October 15th, 2010

In a recent news relsease, AHA’s CEO Nancy Brown said, “Too often, our nation’s vulnerable populations face enormous difficulties securing quality and affordable coverage in the health care system. Many children born with congenital heart disease or stroke have been unable to obtain health insurance coverage in the non-group market because they have a pre-existing medical condition. Today, Health and Human Services Secretary Sebelius reminded states and insurance companies of their role in ensuring children and their families have health coverage options secured under the Patient Protection and Affordable Care Act.”

Read the full statement here.
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Are you ready for September 23rd?

Monday, September 20th, 2010

September 23rd marks the six-month anniversary of the Affordable Care Act being signed into law- and for the 81 million Americans living with heart disease or stroke, and the millions more at risk, it is definitely a date to take note of. That’s because a number of new health care protections, which will help improve patients’ access to affordable care, will take effect that day.

Do you know what this means for you?

If not, you’re not alone. That’s why the American Heart Association is here as a resource for patients and their families. As an informed consumer, it is critical for you to understand what’s changing and what options are available to you in order to access and afford the quality care you need and deserve.

By visiting our website,, you will find:

1. Information about the patients protections taking effect this week, such as:

- Eliminating lifetime caps on coverage and restricting annual limits

- Prohibiting coverage denials to children based on pre-existing conditions

- Allowing young adults (under age 26) to remain covered under their parent’s plan

- Providing preventative services for free under new health plans (and in Medicare starting January 1)

- Prohibiting insurance companies from rescinding coverage if you get sick

2. A series of short videos featuring AHA experts who answer your fellow volunteers’ questions about the health care law and the new protections mentioned above.

3. Links to other resources to provide you with additional information and tools to learn about the protections and options available to you.

The American Heart Association has long recognized that ensuring patients have access to the care they need is critical to our mission of building healthier lives free of cardiovascular disease and stroke. We hope you will seek out the information you need to learn about how the new law will affect you, so you can take full advantage of these new consumer provisions and patient protections.

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We Want to Hear Your Story!

Wednesday, September 1st, 2010

With implementation of the new health care law underway, making health care coverage more accessible and affordable to millions of Americans, we want to hear your health care story!
By sharing your personal story about the new health care reforms that have benefitted you or your family, you can help educate your fellow heart disease and stroke patients about the new coverage options and protections that may be available to them as well.

  • Do you have a child with a pre-existing condition who is now eligible for coverage?
  • Have you encountered problems with lifetime caps in the past- which are now prohibited?
  • Are you a young adult (under 26 years old) who can now stay covered under your parent’s plan?
  • Have you put off preventive care in the past because you couldn’t afford it?
  • Are you or someone you know enrolled in the new Pre-Existing Condition Insurance Plan?
  • Are you a senior who has recently received a rebate check to make it easier to purchase prescription drugs?
  • Have you had your insurance policy cancelled after you got sick, which is now prohibited?

If you fit any of the profiles above, let us know! Your story won’t be used without your consent, but as opportunities to share patient stories come up, whether it is on the web, through the media, or at events, we’ll be able to reach out to you to discuss your interest in helping further.

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Get Answers to Your Questions about the New Health Reform Law

Wednesday, September 1st, 2010

If you’re like most Americans, you have questions about how the new health care reform law, the Affordable Care Act, will affect you and your family. A number of new protections and reforms take effect on September 23rd, the six-month anniversary of the law. The American Heart Association has launched a series of brief videos in which AHA experts will answer some of the most common questions posed by patients and consumers about the new law. To view these videos, visit

It’s important that all consumers know about the new protections afforded to them in their dealings with their insurance companies. The following insurance reforms are among those that take effect starting with health insurance plan years beginning on or after September 23rd (for many Americans, this will be January 1, 2011):

  • Children under age 19 can no longer be denied insurance coverage because they have a preexisting medical condition;
  • Health insurance plans can no longer cancel coverage when an individual becomes sick (except in rare cases of fraud);
  • Young adults without their own employer-provided health insurance are able to stay on their parents’ policy until age 26;
  • Lifetime caps on insurance coverage are prohibited;
  • Annual dollar limits on coverage are being phased out, beginning this year. For plan years beginning after September 23rd, 2010, annual dollar limits lower than $750,000 will be prohibited;
  • New private health plans and some existing health plans are required to cover evidence-based preventive screenings and services at no additional cost to the consumer;
  • New private health plans and some existing plans are prohibited from requiring individuals to get prior approval before seeking emergency care at a hospital outside of their plan’s network and they can no longer charge higher co-pays or deductibles for emergency care received at an out-of-network hospital; and
  • New Preexisting Condition Insurance Plans are available in every state to provide health insurance to individuals who have a preexisting medical condition and have been uninsured for at least six months.

The new videos launched by the American Heart Association provide more information about many of these new provisions of the law. In the videos, AHA CEO Nancy Brown, AHA President Dr. Ralph Sacco, AHA Past President Dr. Clyde Yancy, and AHA Chief Science Officer Dr. Rose Marie Robertson answer questions about these new protections. To watch the videos, visit

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AHA’s CEO issues statement on new dependent coverage regulation

Wednesday, May 12th, 2010

The American Heart Association applauds the Administration for issuing regulations today that will allow young adult children to remain on their parents’ health insurance until age 26. In addition to helping more young people obtain the care they need to remain healthy, this new law affords important protections for young adults with congenital heart defects or other pre-existing conditions. Children and adults with congenital heart disease face many challenges in finding affordable and adequate health care coverage. As a result, some young people delay necessary treatments or skimp on medications to avoid costs, often with serious medical consequences. This new rule will allow many young adults to remain covered under their parents’ medical plans until they are better established and able to afford coverage on their own or get coverage through an employer.
To learn more about the dependent coverage regulation, visit the Health and Human Services Department’s resources.
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Your Health Care Reform Questions Answered- Part 2

Monday, August 10th, 2009

Thank you, Barb, for posting your questions and personal experience in response to our last post about Health Care Reform. We will address questions today regarding the affect on those who have coverage now and funding for health care reform. I would encourage others to share their questions as well, by commenting on this post.

Q: Will I be able to keep my current health insurance coverage if I want to?
Yes. If you currently have health insurance coverage and you like that coverage, you’ll be able to keep it. We recognize, as does President Obama and Congress, that most Americans who are currently insured receive their coverage through their employer and two-thirds of them are satisfied with that coverage.

Q: Will the health care reform bills mean that I will pay more if I have good coverage now?
A: The goal of health care reform is to make health care more affordable for individuals and families as well as for our nation. Americans pay more for our health care than any other country, in part because we are covering the uninsured in a very inefficient way after they get sick and seek care at an emergency room. Some estimate that individuals with insurance pay up to $1,100 more per year through higher premiums and taxes because of uncompensated care received in public hospitals and emergency rooms.

Q: I’ve heard that health reform will cost at least $1 trillion – is this true?
: The $1 trillion cost that has been reported in the media is the cost over a 10-year period (an average of $100 billion a year). It is also important to note, however, that Congressional budget rules require that the health reform bills be fully paid for so that they won’t add to our national debt. The cost estimate also doesn’t take into account the private savings that would result from health reform through such provisions as improved care coordination and a greater emphasis on preventing disease. Finally, we need to consider the cost of delay and inaction. Without reform, costs are projected to continue to escalate, 16 million more Americans are projected to lose their coverage over the next decade, and millions more will have their out-of-pocket health costs rise substantially.

Stay tuned for answers to more questions over the next few weeks. In the meantime, share your questions with us by commenting on this post!

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