You Also Can't Keep Your Doctor

By Edie Littlefield Sundby

Sunday, November 03, 2013

Everyone now is clamoring about Affordable Care Act winners and losers. I am one of the losers.

My grievance is not political; all my energies are directed to enjoying life and staying alive, and I have no time for politics. For almost seven years I have fought and survived stage-4 gallbladder cancer, with a five-year survival rate of less than 2% after diagnosis. I am a determined fighter and extremely lucky. But this luck may have just run out: My affordable, lifesaving medical insurance policy has been canceled effective Dec. 31.

My choice is to get coverage through the government health exchange and lose access to my cancer doctors, or pay much more for insurance outside the exchange (the quotes average 40% to 50% more) for the privilege of starting over with an unfamiliar insurance company and impaired benefits.

Countless hours searching for non-exchange plans have uncovered nothing that compares well with my existing coverage. But the greatest source of frustration is Covered California, the state's Affordable Care Act health-insurance exchange and, by some reports, one of the best such exchanges in the country. After four weeks of researching plans on the website, talking directly to government exchange counselors, insurance companies and medical providers, my insurance broker and I are as confused as ever. Time is running out and we still don't have a clue how to best proceed.

Two things have been essential in my fight to survive stage-4 cancer. The first are doctors and health teams in California and Texas: at the medical center of the University of California, San Diego, and its Moores Cancer Center; Stanford University's Cancer Institute; and the M.D. Anderson Cancer Center in Houston.

The second element essential to my fight is a United Healthcare PPO (preferred provider organization) health-insurance policy.

Since March 2007 United Healthcare has paid $1.2 million to help keep me alive, and it has never once questioned any treatment or procedure recommended by my medical team. The company pays a fair price to the doctors and hospitals, on time, and is responsive to the emergency treatment requirements of late-stage cancer. Its caring people in the claims office have been readily available to talk to me and my providers.

But in January, United Healthcare sent me a letter announcing that they were pulling out of the individual California market. The company suggested I look to Covered California starting in October.

You would think it would be simple to find a health-exchange plan that allows me, living in San Diego, to continue to see my primary oncologist at Stanford University and my primary care doctors at the University of California, San Diego. Not so. UCSD has agreed to accept only one Covered California plan—a very restrictive Anthem EPO Plan. EPO stands for exclusive provider organization, which means the plan has a small network of doctors and facilities and no out-of-network coverage (as in a preferred-provider organization plan) except for emergencies. Stanford accepts an Anthem PPO plan but it is not available for purchase in San Diego (only Anthem HMO and EPO plans are available in San Diego).

So if I go with a health-exchange plan, I must choose between Stanford and UCSD. Stanford has kept me alive—but UCSD has provided emergency and local treatment support during wretched periods of this disease, and it is where my primary-care doctors are.

Before the Affordable Care Act, health-insurance policies could not be sold across state lines; now policies sold on the Affordable Care Act exchanges may not be offered across county lines.

What happened to the president's promise, "You can keep your health plan"? Or to the promise that "You can keep your doctor"? Thanks to the law, I have been forced to give up a world-class health plan. The exchange would force me to give up a world-class physician.

For a cancer patient, medical coverage is a matter of life and death. Take away people's ability to control their medical-coverage choices and they may die. I guess that's a highly effective way to control medical costs. Perhaps that's the point.