Obama's Pre-Existing Condition Insurance Plan: A Patient's View

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In September of 2009 I blogged here about a letter I wrote to the President and my Senators about prescription drug costs. That post, called My Big Fat $7,575.00 Annual Prescription Bill, received a good amount of traffic, so I thought I would do a follow up.

When Congress passed the Affordable Care Act in March of 2010, it provided some relief for my immediate problem, which was the cost of my prescriptions. This post will look at how the act addressed my problem from a practical perspective, rather than a political perspective. There are many articles that address the politics of the Affordable Care Act, if you want to read about that. I'm focusing on practical issues because, as a patient who depends on drugs every day, that was what I needed to deal with regardless of whether I agreed with the politics behind the act.

As background, my situation as a patient in March 2010 was this: I was self-employed, had two pre-existing conditions that required daily medication, and I could not buy private health insurance at any price. I was paying full price for prescriptions inside the U.S. at an annual cost of $7,575.00 (for more detail on this, see my previous blog post). In addition to my prescriptions, I was paying whatever rate I could get for office visits to see my physicians (I usually received a 10% discount as an uninsured patient).

The Affordable Care Act established the Pre-existing Condition Insurance Plan (PCIP), a for-pay program that provides insurance to people like myself who have been refused individual private health insurance. The PCIP program is administered either at the state or federal level; it varies by state. California missed the established deadline for implementation of its PCIP program and several months passed before it was up and running. When California finally announced that applications to the program were available, I downloaded the paperwork and filed my application on the first day they were being accepted. Within a month, I had PCIP insurance.

Once my insurance card arrived, I used the information packet that came with it to add up how much I might expect to spend in the coming year on prescription drugs and health care services. Refreshingly, it was a simple matter to tally my drug costs under the PCIP program. There was a $100.00 deductible for brand name drugs, which I would breeze through in the first month with just one prescription. After meeting the deductible, brand drugs had a co-pay of $5.00. All generic drugs also had a co-pay of $5.00.

I was glad the PCIP program offered flat fee co-pays instead of percentage-of-price co-pays for drugs. It is much easier to budget with a flat fee co-pay. It means I don't have to keep track of the retail price of all my drugs, which may increase in price more than once over the course of a year. It also means I don't have to call pharmacies to track down the lowest price available for multiple drugs. Although PCIP does have a $100.00 deductible for brand drugs, I was pleased to see they did not create a higher co-pay for brand drugs.

To find the true cost of my prescriptions, I also had to add the cost of the insurance premiums that bought me that discount. The California PCIP program's insurance rates are based on age and locale. I found my age and location in the rate table and discovered my premium was $371.00 a month. Then I guessed at the services I would need in a year: two specialist visits, a physical, a pap smear, a mammogram and a flu shot. Plus I added in an extra doctor's visit and drug co-pay in case I came down with an infection. Most visits had flat fee co-pays and several fell under the category of preventative care, so there would be no co-pay.

When I added up the year's costs for prescriptions, co-pays on office visits, and premiums, the total was roughly $20.00 less than my previous year's drug costs. Comparing my previous year prescription costs to current year prescription costs plus premiums, my costs were a few hundred dollars lower under the PCIP program.

The bad news was that, overall, my health care costs were going to remain extremely high. The good news was that I was getting a lot more for my money. I now had insurance coverage and could take care of basic medical visits, get recommended preventative care and fill my prescriptions for the cost of what I paid during the previous year for drugs alone.

I worry a lot less now because I have insurance coverage. With insurance, I feel free to attempt to change or lessen my use of a specific medication under a doctor's care. Before, when I had no insurance, I was fearful of trying to switch to a less expensive or different drug in case a bad reaction put me into the emergency room, with costs I would have to bear myself. Less worry and less stress equals more health.

On August 1, the California PCIP implemented a premium rate reduction. My premiums went down from $371 a month to $306 a month. I am very happy the program has been made more affordable, because affordability is a continuing problem with health care, as is the overall fragility of the health care system. But as long as I am still eligible and have the money for premiums, I expect to continue with PCIP.

1 Comment

Too bad you're not a Republican senator. You wouldn't have any of these concerns. You'd be too busy foaming at the mouth about deficits while not mentioning two 10+ year wars costing billions of dollars a year.