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Utah's Uninsured

Without insurance, I couldn’t get any preventative care. This made my heart disease worse to the point where I needed expensive heart surgery…

Royal M., Age 57

Royal worried daily about being uninsured. He hoped that he did not get sick or need to go to the hospital. Royal recently thought he was coming down with a minor cough; he tried home remedies, but nothing seemed to work and the cough wouldn’t go away. As the cough got worse, Royal went to the free clinic downtown where they realized he had a massive infection around his heart and sent him straight to the emergency room of the nearest hospital. Though he was unable to pay for his ER visit, Royal underwent emergency heart surgery.

Preventative care is the best remedy…
If Royal had insurance he could have seen a doctor and prevented his heart surgery and further complications. “Without insurance, I couldn’t get any preventative care. This made my heart disease worse to the point where I needed expensive heart surgery…”

Conflicting income streams prevented eligibility for Medicaid… Royal received Medicaid for 2 months while waiting to be approved for Social Security Disability. However, when he started receiving his checks he was cut off from Medicaid and told he made too much money from SSDI. He simply cannot afford the Medicaid ‘spend  down’ (Medicaid’s version of a deductible), which means that he is once again uninsured.

The Patient Protection and Affordable Care Act helps individuals like Royal in a variety of ways:

Starting in 2010, there will be increased funding for Community Health Centers to allow for nearly a doubling of the number of patients seen by the centers over the next 5 years.  Community Health Centers charge a sliding fee scale based on income, thus making care more affordable for someone like Royal.  

Also in 2010 there will be new standards for non-profit hospitals to protect uninsured patients. These protections include written financial assistance policies clearly stating eligibility guidelines & how to apply, protections from being overcharged, and measures that prohibit extraordinary collection actions against patients. Another important change for Royal is that his eligibility levels for Medicaid cannot be reduced.

And finally, an interim high-risk pool will be established to provide immediate access to insurance for Utahns who for at least 6 months have not been able to get coverage because of a pre-existing condition.

In 2013, Medicaid payments for primary care services provided by primary care doctors increased, giving Royal greater access to physicians than he has today.

And in 2014, individuals like Royal will be able to obtain insurance even with their pre-existing conditions; they will be able to buy insurance through a new online, state-based marketplace called an exchange.  Based on income, there will be a cap to the amount a family will be charged for premiums and out-of-pocket.

Medicaid will be expanded to all individuals under age 65 with incomes up to 133% FPL.  In addition, adults cannot be denied coverage for pre-existing conditions nor can health premiums be rated based on health status.  Health plans will also not be able to impose annual or lifetime benefit caps.