I keep good track of healthcare policy conversations. I was and am a supporter of the Affordable Care Act (known colloquially as Obamacare). I’m personally grateful it prohibits discrimination against patients with pre-existing conditions, like BRCA mutations or depression or high cholesterol, because it means that I no longer worry that I’m uninsurable.
I am a healthy 34 year-old woman – but I’m BRCA1 positive, meaning that I’m high risk for breast and ovarian cancers. I pay attention to my health – and my healthcare.
Within arm’s reach of the desk where I spend most of my waking hours, there’s a fat file folder labeled “Health Care 2014”. It’s riveting stuff: a January bill from my high-risk gynecologist and the radiologist for my baseline mammogram ($253 billed/$75.58 paid). That bill is followed by a note with the “Great news!” that my mammogram looked good (which, thank god, since I’d had a mastectomy three years ago and this was to monitor residual tissue). Then there’s another mammography bill ($504/$144.76); results from ovary-related bloodwork and the bill for that ($152/$121.93); another mammography bill ($293/$79.93); a bill for May transvaginal ($653) and pelvic ($736) ultrasounds, with payments too complicated to detail; followed by an identical bill (another $673 + $736) from July after my doctor saw a mass in May she wanted to monitor. Then, her letter reassuring me that the various things growing in my ovaries weren’t cancerous .
It goes on, but you get the point. If I didn’t have insurance, either because it was too expensive or because of my preexisting condition, that preventative medical care would have cost me $5,956 this year (and there’s still six weeks to go in the year) – and I make less than $40,000 annually. Because I have insurance, I paid $674.67.
While I pay attention, I am no policy expert and admittedly have trouble with words like “deductible”, “HMO”, “premium” and “benefit” – all of which sound to me like an English dialect I do not speak.
But after the Republican-led government shutdown in October 2013, it was clear to me that the 2014 midterm elections would have repercussions for healthcare reform. And, as all those GOP wins piled up last week, the Republican victory lap included a lot of noise about repealing the Obama administration’s signature achievement.
But trying to figure out which specific clauses of the Affordable Care Act are most vulnerable to Republican shenanigans felt like off-roading it blindfolded from the Capitol in Washingon DC to the Virginia state capital in Richmond – long, tedious and totally in the dark. For help I turned to a most erudite panel of experts: my friend Joey who went to business school and who I therefore believe understands policy; and my friend Laura, a medical school student.
Both my friends and the internet agree that the preexisting conditions clause is too politically popular for repeal. All of us – even Ted Cruz – probably have a mutation inside us that foretells our doom; it’s just a matter of whether it has yet been identified by science. So, I feel reasonably safe that my insurer won’t suddenly be able to drop me based on my genes.
The most immediate challenge is the case now under review by the US supreme court, which questions whether the federal exchanges can provide tax credits to those in states that opted out of the exchanges. Virginia, where I live, participates in the federal exchange with state oversight – but I’m covered by my employer so I’m safe there – or as safe as anyone can be when their insurance is dependent on a job in an at-will employment economy.
But because it creates a sense of universal obligation and presumes a right to health care, the mandate that we all have health insurance is the political sticking point for conservatives. Should that block be removed, the Jenga tower of the whole law would collapse. So Laura said if she were a Republican congresswoman she’d start there – but the numbers aren’t there to override a veto.
OK, I thought, whatever happens, I am not afraid for myself.
But it’s also not just about me. My thick folder of medical bills means that I’m acutely aware of the personal impacts of some implications of the health care debate, but it’s not why I support the law. I simply do not understand the reluctance we seem to have to take care of each other.
One of the most important parts of Angelina Jolie’s galvanizing editorial for the New York Times about her own BRCA1 diagnosis and subsequent preventative mastectomy was her acknowledgment of the need “to ensure that more women can access gene testing and lifesaving preventative treatment, whatever their means and background.”
Like everyone, Jolie’s planet of privilege is as familiar to me as Mars (see: my $40,000 salary) but, all things considered, my position is enviable. The people I worry for are those who are BRCA1 positive but unaware and struggling financially. I worry for those without doctor friends to help evaluate insurance plans and who risk getting duped by the gibberish they send you before you enroll. What if you can’t afford the co-pay for the mammogram – even though it’s covered under the ACA – so you don’t have one at all? What if by some act of sheer political will, Republicans do manage to repeal significant parts of the law, and you’re thrown back into that Wild West of pre-ACA insurance plan selection, and choose a bogus plan with such a high deductible it bankrupts you?
Whatever the future of the ACA, the idea that scares me the most – and has from the start – is that you think you’re healthy until one day you aren’t, and you’re left not just looking for, but needing help. That’s a potential future to which no one is immune.
