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Utah's Uninsurable

Bobbie and her family had health insurance. But once their daughter needed to use it to treat her disabling condition, their private
insurance left them stranded.
Bobbi, Age 52

Bobbi is the mother of 3 children. Her youngest child, Katie, has DiGeorge Syndrome. The Mathews were covered with private insurance, but when their daughter turned 9-years-old and reached the insurance’s lifetime cap, Katie was left without any coverage. To get the care that Katie needs to stay alive, this hardworking Utah family was forced to spend down their assets and enroll Katie in Medicaid.

Having Insurance does not guarantee coverage when you need it most:
Bobbi works as a Human Resources Benefit Specialist at a local Company and is the proud mother of three children. Thirteen years ago, Bobbi gave birth to her youngest child, Katie.

Katie has DiGeorge Syndrome, which affects the heart, immune system, and parathyroid. Bobbi and her husband had health insurance through their employer for their family. It helped pay for the hospitalizations, the home nursing care, and surgeries that Katie needed. The Mathews were doing all the right things— paying for insurance through their employer, working to provide for their family and ensuring their daughter had quality care. However, by the time Katie was 9 years old, she reached the life-time cap of what the private insurance would pay. They were left stranded with no coverage for their daughter. Knowing that her daughter’s condition meant ongoing medical needs, Bobbi enrolled Katie in Medicaid.

At first, the Mathews were successful participants in the private insurance market. But once their daughter was identified as an excessive risk patient, it did their insurance coverage stopped being of use. They were unable to stay in the private market, and the taxpayer was ultimately forced to take on the risk. Tools within health system reform that might have helped the Mathews family stay in the private sector are establishing community rating and a market facilitator, allowing the family to change insurances after Katie reached the lifetime cap.

In addition to growing government programs, the Mathews family had to comply with Medicaid’s asset test and spend-down requirements. This hampers the economic strength of the family. The Utah State Legislature should consider eliminating the asset test, though maintain the income test. This will greatly increase the economic strength of a family and give them the ability to save—a key tool for enhancing wealth.

The Patient Protection and Affordable Care Act (PPACA) Prohibits Lifetime and Annual Benefit Caps

PPACA eliminates lifetime caps on essential benefits provided under group health plans. This prohibition on lifetime caps is effective six months after enactment of the bill (September 23, 2010). Additionally, the PPACA places restrictions on annual limits that may be imposed upon plan participants.