Bending the Rules to Access Health Care

On Tuesday, the Senate Finance Committee passed a long-awaited centrist health care bill.  Now, majority leader Harry Reid will try to create a filibuster-proof version to bring to the full Senate. If it passes, the health care overhaul will make it significantly easier for many people to get health insurance. One group that is sure to benefit is young adults, who are currently uninsured at higher rates than any other age group in America.  

Today, we have the third and final installment in our series on young, uninsured professionals. In the last two weeks, we’ve heard why some of them go without health care, and we’ve heard the difficulty others have trying to navigate the public safety net. 

But for some people, neither of those options is workable. If you make too much money to qualify for public assistance – but not enough to afford health insurance – you’re stuck. If you can’t get private health coverage due to a preexisting condition – but you live in an area without a robust public health network – you’re stuck. Some uninsured young adults feel they have no choice but to bend or break the rules. KALW’s Zoe Corneli reports. And, a note to our listeners – the identities of people in this story have been concealed to protect their privacy. 

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ZOE CORNELI: For Michael Lee, having health insurance was always a priority. When he finished college on the East Coast, he chose to volunteer with Americorps, in no small part because it offers insurance. When that ended, he bought a short-term policy covering catastrophic injury or illness... and he headed West to Portland. 

MICHAEL LEE: My mother’s you-always-have-to-have-health-insurance ethic had really been grinded into my brain at that point, so I was spending probably 300 of the thousand dollars I had in my bank account…  

CORNELI: Once there, he started looking around for a more permanent solution. 

LEE: So somebody told me, there’s something here called the Oregon health plan, it’s health insurance for poor people, or people without a lot of money, and I was like, no way, that’s crazy. 

CORNELI: Lee applied, and was asked to verify his income from the past three months. 

LEE: So, my last three months’ income was zero. So I got signed up for the Oregon health plan, and it was great. 

CORNELI: Lee says he didn’t use the coverage much, except to get some dental work done. But having it allowed him to pursue his dreams of doing nonprofit work and freelance photography without having to worry about health insurance. Soon, though, his part-time jobs started to pay enough to push him over the income limits. 

LEE: I was making about $10,000, $11,000 a year, and they were saying if you’re making more than $9,000 you’re not qualified, which is really absurd. 

CORNELI: Absurd, he says, because his earnings were nowhere near sufficient to purchase health insurance on the private market.  

LEE: And that’s part of why I felt fine telling them that my income was lower than it actually was, because I was poor. And this health plan, the Oregon Health plan was designed for poor people. 

CORNELI: Lee would only show some of his pay stubs. Or, he’d choose to reenroll at times when he was between jobs. 

LEE: So I would just really work around the margins of the eligibility system, not report some income.  

CORNELI: This went on for two years, until the end of 2002. 

LEE: I received a letter saying they wanted some more proof of my income, maybe something had come up fishy in the numbers I had given to them, I don’t remember exactly how. 

CORNELI: So he sent in a copy of his bank statement… 

LEE: And then I got a phone call on new year’s eve, and the woman was saying I’m with the Oregon health plan and we’re trying to verify some details with your application…  

CORNELI: She said his bank deposits were higher than the income he had reported. 

LEE: And I started to panic, and I didn’t have a good answer at the time, and I said, oh well, that’s because my roommates have been giving me checks, and then I would pay the whole rent to our landlord… 

CORNELI: But the health plan representative wasn’t convinced. 

LEE: She said well in the meantime, we’re gonna have to cut you off the health plan, you can reapply, but it doesn’t appear that you’re under the limits. And I started pleading with her, I was like, I don’t have any money, what am I gonna do, I need health insurance, I was kinda freaking out. And she said I wish I could help you, I really do. And that was the end of my enrollment on the Oregon Health Plan.  

CORNELI: The Oregon Department of Human Services allocates significant resources towards what it calls “program integrity” – making sure the people on the plan are the ones it’s intended to serve. Program Manager Karen House says being even slightly over the income requirements is enough to disqualify you.  

KAREN HOUSE: Because of funding limitations and budget limitations, we are not able to cover all the individuals we would like to be able to cover, all those who are currently uninsured. Especially in the adult populations. 

CORNELI: She says if a lot of people did what Michael Lee did, it could overwhelm the system.  

HOUSE: Because of the limited funding, I mean, it could be that people who really are eligible and should be receiving coverage, it might not be available for them.  

CORNELI: As for Lee, once he was kicked off the program, he stayed in Portland, uninsured, for another year, before moving across the country for a job that offered health insurance. 

LEE: And it was a real job with real benefits, and it turned out good. 

CORNELI: Sometimes, though, having a, quote, “real” job isn’t enough. Shannon Jones has a career. She has a college degree. She has a comfortable income. What she doesn’t have is health insurance. 

CORNELI: When I meet her in her home in the Oakland hills, she’s reading the newspaper, looking for the latest information on health care. 

SHANNON JONES: I’m thinking about it a lot more than I used to, just because it’s in the news every single day, and I’m reading it constantly ‘cause I want to know every little thing that’s happening. 

CORNELI: A few years ago, Jones left her longtime marketing job to become an independent. COBRA allowed her to keep her health insurance for a year and a half. Then she switched to HIPAA. But that was expensive. 

JONES: I think it started off in the high 300s but then by the time I was done, it went up to 450, 455 a month. 

CORNELI: Then the economy collapsed, and her business did too. 

JONES: Last year, 2008, it was down 50 percent from 2007, and then in the first six months of this year versus half of a year last year it’s down two thirds. 

CORNELI: To save money, Jones cancelled her health care coverage. She tried applying for private insurance instead… 

JONES: …through a couple different brokers and some alternative insurance plan options, and no one would take me. Including Kaiser. 

CORNELI: Now she has few options. There are some free and low-cost clinics in the East Bay, but most of them have restrictions, like they’ll only see the first ten clients, with priority given to the homeless… or, you have to call exactly at 5:45 p.m. to get an appointment… or they won’t see patients for concerns located on the face or below the waist. Alameda County has a sliding scale program at its hospitals and clinics, but as an individual, you have to make less than 20 thousand dollars a year to qualify. 

Jones hasn’t seen a doctor for over a year... And that’s dangerous, in part because she suffers from type-2 diabetes. Also… 

JONES: My mother had breast cancer, so my doctor told me I think a year or two ago, that I should start having mammograms, and are you kidding me, that’s not even remotely possible. 

CORNELI: She’s biding her time to see if a national health care overhaul will pass by the end of this year. If it doesn’t, she says, she has one choice left. 

JONES: There is a way to apply for insurance basically through the backdoor. 

CORNELI: That would be to get on a small business group plan. 

JONES: But to do that you have to have two employees. 

CORNELI: Shannon doesn’t have employees… 

JONES: Long story short I would have to hire my brother… 

…Get him set up on payroll, pay all of his taxes and salary, and then he would pay the money back. 

JONES: I could carry him for 2-3 months and then I would have to fire him, quote unquote, and then I could keep my small business plan, even though I would be the only one on it. 

CORNELI: There’s no way to know how commonly patients use deception to access health care. But when I sent out a query asking for people to share this kind of experience, I received a flood of responses. One of them was an attorney, who had underreported his income to get coverage for his children. Others misrepresent their finances to access San Francisco’s city-provided health care. Tangerine Brigham, director of Healthy San Francisco, says she knows these violations sometimes happen. When they come to light, she says the offenders are kicked off the program.  

TANGERINE BRIGHAM: But quite frankly, we would rather spend the precious dollars that we have, providing service. Than spend those dollars on administration verifying that the copy of someone’s tax return was in fact the one that they actually filed.  

CORNELI: Brigham thinks we should expand the eligibility requirements for public health programs. 

BRIGHAM: We all know that there will be people who game systems irrespective of what an eligibility rule is. But I believe that that is far and few between, and when people are doing this it is because desperation has set in for them. 

CORNELI: Statistically speaking, nearly two thirds of uninsured young adults are very low income.  Some counties, like San Francisco, provide health care coverage for them. In most, however, low wage earners have been priced out of the insurance system, and they’re nearly out of options. Some, like Shannon Jones, are faced with a choice: ignore their health care needs... or lie. 

JONES: I really struggle with it, to be honest with you, ‘cause it is an ethical dilemma for me. This is not something I’d do in any other situation, it doesn’t feel right, and there’s definitely a disconnect. But – I’m desperate.

CORNELI: For Crosscurrents, I’m Zoe Corneli.


Audio file