Samantha Gibson and her husband have always paid for their own health insurance.
The Beach Cities natives run their own distribution business in Torrance, delivering wholesale dairy products to schools, donut shops and daycare centers. As their own employers, they cover the cost of premium payments to insure themselves and their three children.
The damage has typically been about $1,000 per month. For years, the Gibsons have been budgeting accordingly.
They understand the value of doing so – after she gave birth to her third child, Samantha was hospitalized for thyroid cancer. Her insurance plan covered every penny of the $100,000 visitation.
But several years ago, the Gibsons’ insurer raised its rates. The family’s premiums jumped to $1,800 per month and their deductible to $8,000. In 2012, they spent $28,000 out of pocket, despite their coverage plan. The year prior, medical expenses and insurance payments combined cost them about $20,000.
“We were looking to buy a house, and we just couldn’t afford that,” Samantha said. “It was getting crazy, insane.”
Shopping for a different plan proved troublesome; insurers were reluctant to cover her family on account of its three pre-existing conditions – Samantha’s cancer, her daughter’s rheumatoid arthritis, her son’s ADHD.
“Nobody wanted to insure us. We felt like we were handcuffed to this company that was increasing its rates,” she said. “It’s scary, living in fear that you won’t be able to afford insurance and something will happen.”
For her, the rollout of the Patient Protection and Affordable Care Act – newly enacted legislation that aims to make healthcare more affordable for all Americans, and to insure the 40 million people who lack insurance coverage – is timely.
For her family, it manifests as similar monthly payments but thousands less in out-of-pocket expenses. It also means peace of mind. Pre-existing conditions will no longer preclude her from shopping for insurance.
“The Affordable [Care] Act does not seem perfect,” she wrote in an email, “but I feel it is a step in the right direction.”
The act heralds the farthest-reaching reform of the healthcare system since Medicare was legislated in 1965. For three years, the Patient Protection and Affordable Care Act – also called Obamacare – has been the subject of heated debate in Congress and at millions of dinner tables.
On both sides of the American political spectrum, strong opinions color discussion of the healthcare system. Some applaud the act as a step in the right direction, at long last; others vehemently believe it will have disastrous consequences. One Louisiana congressman called it the most “dangerous” piece of legislation ever passed.
Politics notwithstanding, the fact remains that the Affordable Care Act has been signed into law, and now the Beach Cities – and all of America – must recalibrate.
Now, like millions of other Americans, Beach Cities residents have a choice: get private insurance, apply for government-sponsored Medi-Cal, or incur a penalty.
Under the Affordable Care Act, all Americans will be required to sign up or pay up.
Beginning in 2014, someone without insurance has to pay a fine – one percent of his or her yearly income or $95, whichever is greater. A child without healthcare will cost his or her parent $47.50. With each successive year, the fine will increase; by 2016, the cost will be 2.5 percent of income or $695 for a single person, and $2,085 for a family.
The act holds insurance companies to different standards. Now they have to cover the cost of services that used to be optional, including mental healthcare and preventive services like cancer screenings. They are also banned from cancelling a policy if a holder gets sick.
For many people, insurance policies and jargon are new concepts. Some have never been insured; some are recently unemployed and uninsured. To avoid fines, all of them have to find an insurance plan, and they don’t have much time to figure it out.
On Oct. 1, the national healthcare insurance exchange – a web-based marketplace – went live and the machine of reform rumbled to life. Now, just over two months later, the deadline for getting coverage looms. Americans have until Dec. 23 to purchase insurance if they want coverage effective Jan. 1, and until March 31 if they want coverage in 2014.
As with any major transition, this one is fraught with complications. Headlines decry the shortfalls of the online exchange. People are confused.
Fortunately for local residents, Beach Cities Health District (BCHD) in Redondo Beach, the nation’s largest preventive health agency, wants to make the shift as painless as possible.
“It’s a new program, so we’re anticipating bumps, but we want to make sure people in the community are supported in the [transition],” said Dr. Lisa Santora, chief medical officer at BCHD.
“Effective January, it’s a mandate that an individual must have health insurance, and we’re working with the community to make sure everyone can meet that new mandate. Just like you have to have car insurance if you drive a car in California, now there’s a mandate that you have to have health insurance.”
On Nov. 18, BCHD announced its certification as an enrollment site through Covered California – the state-run online marketplace created to facilitate the buying and selling of healthcare insurance. Covered California aims to enroll more than 700,000 people before the March deadline – as of Nov. 19, 80,000 California residents had chosen a coverage plan – and BCHD has signed on to be part of that effort.
Four staff members have undergone training to qualify as enrollment counselors. Their certification can be verified on the Covered California website.
“We want to help [guide] people the correct way through what could be a very complicated healthcare system,” Santora said. “As simple as the exchange has made it, it can be confusing. What’s a deductible? What’s a premium? If you’ve never had health insurance in your life, you might not know what those are. We want to make sure people are not only able to have health insurance but also to understand it and fully utilize it.”
The district is uninvolved with the politics healthcare reform, but resolute in its commitment to ensuring that all Beach Cities residents have access to affordable healthcare, Santora said.
“Regardless of whether someone supports [healthcare reform] or doesn’t, our thing is that it’s bigger than that,” added Eric Garner, BCHD’s communications specialist.
“We’ve always made it our duty to make sure our residents have access to healthcare and health services. We’ve been doing it for 20 years and this is just another arrow in our quiver. If it’s connecting people with healthcare, we’re on board.”
As testament to that, the district has for more than a decade operated the Center for Health Connection, which provides need-based and fee-based medical, dental, and counseling services to local residents who qualify.
“One of our priorities at the health district has always been ensuring 100 percent access to healthcare coverage,” Santora said. “Because you can’t be 100 percent healthy if you don’t have access to a medical home or if you don’t have healthcare insurance coverage.”
Santora sees the district’s certification as a Covered California enrollment site as another manifestation of that basic commitment to connect people with healthcare.
She adds that there is one particular aspect of healthcare reform that aligns with the BCHD vision: the requirement that all insurance plans cover preventive services. As a preventive healthcare agency, BCHD operates according to the principle that by pre-empting sickness and disease – getting check-ups, pap smears, and cancer screenings, for example – patients save money and live longer.
“Having insurance will help people access preventive services that will increase their life expectancy,” Santora said. “We strive to connect people with healthcare resources that prevent them from developing conditions that could be seriously debilitating.
“Right now we’re working with a lot of residents who… might not understand the need to have health insurance. If you’re 27, health insurance might not be your top priority. We want to work with the community to help them see it’s better to be insured.”
According to the Kaiser Family Foundation, a non-profit healthcare policy watchdog with no relationship to Kaiser Permanente, California entered the reform era with a percentage of uninsured residents that was greater than the national average.
Of its nonelderly population, 22 percent of California lacked coverage. The national figure was 18 percent. The coverage gap in the Beach Cities was less than half that.
“The majority of Beach Cities residents do have access to health insurance or self fund [coverage], but always there has been a population in the Beach Cities of people who have not had that access,” Santora said.
In the Beach Cities of Hermosa Beach, Manhattan Beach, and Redondo Beach – an affluent area with a combined population of more than 120,000 – seven percent of residents lacked insurance in 2010, according to a Gallup Well Being Index survey. At the time the survey was conducted, the majority of the Beach Cities’ uninsured population comprised people between the ages of 18 and 30 – a statistic, Santora said, that corresponded with the high numbers of young service industry workers in the area whose employers do not sponsor their health insurance.
Over 17 percent of people between the ages of 18 and 29 were uninsured; just over eight percent of people aged between 45 and 64 years old lacked coverage. Thousands more, like the Gibsons, were barely hanging on to their insurance plans.
Another Gallup Well Being Index survey conducted in 2012 revealed a change in the demographic of people without coverage. Already, the Affordable Care Act was allowing everyone under the age of 26 to remain under their parents’ insurance coverage (even if they lived away from home), which manifested as a decrease in the number of young adults without insurance.
Now, 11 percent of people between 18 and 29 lacked coverage, compared to nearly 18 percent two years earlier. But the survey revealed a new trend: the percentage of uninsured people between the ages of 45 and 64 had jumped almost 4 points, from 8 percent to nearly 12.
“There was the economic decline and a lot of older people facing layoffs and economic shifts – and it’s a lot harder to find a job when you’re over 50, but you still don’t qualify for Medicare, so that was a new gap we found,” Santora said.
Over 7,000 people were still without access to healthcare – the bulk of that population in Redondo Beach.
But because the gap is significantly smaller locally than it is in other, lower-income areas, resources for uninsured people are scarce.
“Often in places of higher need – Venice, Santa Monica, South L.A. – that’s where the county places services for people who don’t have access to healthcare,” Santora said. “For a Beach Cities resident, it’s always been very challenging to get access to healthcare when they weren’t insured.”
These are the people BCHD had in mind when it applied to become a certified enrollment site – people like one of Santora’s patients, an unemployed 27-year-old student who recently used the BCHD counseling service to sign up for healthcare coverage that will cost him less than $70 per month.
“Two years ago, an appendectomy [would have] cost him $12,000,” Santora said. “Now he’s paying less than he pays for his iPhone and if something like that happens he’s not going to be forced into bankruptcy for something that was unexpected.”
Before she was laid off, Redondo Beach resident Serena Smith* didn’t pay much attention to healthcare insurance.
Her boss covered her premiums. She didn’t know how much they cost; she didn’t have to.
But then the recession struck and, like thousands of other Californians, Smith was laid off. Now, she is engaged in a job hunt, but until it bears fruit she has no income. Her expenses include rent for an apartment in Redondo Beach and tuition for a graduate program at UCLA that she hopes will increase her chances of finding a job she wants.
Until this month, she had no healthcare coverage.
Recently, Smith learned from her next-door neighbor about the service being offered at BCHD. Eager to better understand the process of applying for coverage, she made an appointment.
Because she arrived with the necessary documents in hand, Smith was able to complete the application within a half hour and walk away insured and reassured.
“It was so quick,” Smith said of her visit to BCHD. “They were able to give me an appointment right away, which was important to me, especially during the holidays. I wanted to get this done and over with.”
After answering a series of questions – “so simple a middle school student can do them,” she said – and choosing a plan to suit her needs, she is breathing a sigh of relief.
“I just feel like I’m much more optimistic about my future,” she said.
All appointments are free and one-on-one.
“We help people digest all of this information because it’s a lot, especially for someone who hasn’t had health insurance for awhile or is just getting familiar with some of the terms and what they mean,” said certified Covered California counselor Heather Hocking. “It can be kind of overwhelming. This is a big decision for a lot of people, and they often don’t even know what they qualify for, so this is a good way to figure that out. And it’s our job to help them.”
Hocking and the BCHD staff are sensitive to the great weight of the decision to purchase long-term coverage, and make it a point not to rush their clients.
“When people say, ‘This is great but I have to talk to my husband’ or ‘I have to think about this,’ we totally understand that,” Hocking said. “We know this is a big decision and are happy to make a follow-up appointment. There’s no pressure to make a decision right then and there.”
Behind closed doors, Hocking and her colleagues show their clients how to use coveredca.com, which features a Shop And Compare tool that juxtaposes insurance packages and informs users as to whether they qualify for subsidies and tax credits.
The tool requires users to input their yearly income, age, ZIP code, and the number of their dependents; it then shows a comparison of healthcare packages and their total cost.
“Then we’ll have a conversation about how often they go to the doctor or whether they have an ongoing chronic health condition,” Hocking said. “We think about different plans where you pay a certain percent and the plan pays a certain percent, based on what you think your needs are going to be.”
Packages fit into one of four categories – bronze, silver, gold, and platinum – based on affordability and level of coverage. Under the Affordable Care Act, every plan is required to cover the following: ambulance services, emergency services, hospitalization, maternity and newborn care, mental health and substance abuse disorder services, prescription drugs, rehabilitative services, laboratory services, preventive and wellness services, and services for children, including dental and vision care.
Examples of these are alcohol screening and counseling, diet and obesity counseling, aspirin use, blood pressure and cholesterol checks, cancer screenings, depression screenings, diabetes checks, HIV screening, immunization vaccines, sexually transmitted infection screening and counseling, tobacco cessation counseling, and preventive health services for women, like breast cancer screening and well-woman visits.
Subsidies are available for people who earn relatively low income – less than $45,000 per year for a single person, or less than $94,000 per year for a family of four. A person like Smith who earns less than $15,856 per year qualifies for Medi-Cal, the state’s Medicaid program that pays for children and adults with limited income to receive medical services.
Smith will have no monthly payments.
Given the national outcry over the technical shortfalls of the enrollment website, Hocking has been pleasantly surprised at how smoothly it has worked for her.
“The website has been really smooth, actually,” Hocking said. “Covered California notifies people when the website is going to be down for scheduled maintenance, but when they take the website down we can still use the Shop and Compare tool. We might have to wait a day to apply, but we can still browse through plans. And scheduled maintenance is few and far between.”
It is a service that will benefit someone like Jessica Lambert, a 27-year-old emergency room nurse, who lost her benefits when she scaled back to part-time in order to devote time to pursuing a new career in the real estate industry.
“I’ve never had to go out and get my own insurance,” she said. “I always got it through work. This is a new experience for me.”
She is anxious to sit down and find a plan that suits her needs; her work has impressed upon her the great value of being insured.
“I see what can happen… I see major, major injuries working in a trauma center,” she said. “Unexpected things, car accidents, random accidents – I know how important insurance is.”
Santora shares that perspective.
“I’m a family physician,” she said. “I’ve seen the downside of not having insurance and delaying healthcare… most doctors have similar war stories about people who haven’t had health insurance and delayed seeking care because they didn’t have access to it.”
Call BCHD at (310) 374-3426 ext. 256 to schedule an appointment on any business day between 8:30 a.m. and 5:30 p.m. Bring with you to your appointment the following: social security numbers, recent income tax filings and, if applicable, legal immigration information or information related to your status as a member of a federally recognized tribe.
*Name was changed to protect privacy