Next year, Nathan Auldridge will be as much a cancer survivor as he has been for the past eight years.
There will be a difference, though, one that he calls life-changing.
Because of his pre-existing condition, Auldridge has been paying $483 a month for health insurance that only starts to help with his medical bills after he meets a $5,000 deductible.
Under a different plan that takes effect on the first day of the new year — and the first day of his new life — Auldridge will pay just $111 a month and have a deductible of $1,750.
The reason, the 30-year-old from Salem says, is a provision of the Patient Protection and Affordable Care Act that prohibits insurance companies from charging more or denying coverage to people with pre-existing conditions.
“It has freed me from a weight, a chain, a prison of costs that were astronomical, especially considering my low income level, ” said Auldridge, who makes about $20,000 a year working with people with autism.
For Auldridge and millions of others like him with pre-existing conditions, the Affordable Care Act codifies what had been a simple yet elusive concept: that sick people should have access to health insurance, and that the plans they purchase should actually defray their medical bills.
In December 2005, when Auldridge was a freshman at James Madison University, he learned that he had a cancerous tumor in his brain.
After major surgery at Duke University to remove the tumor, followed by a six-week stay in the hospital, followed by six months of radiation treatments, Auldridge was declared cancer-free.
But he was hardly free from a medical history that was just beginning. Auldridge soon developed narcolepsy, which he believes was the result of either his surgery or the radiation that followed.
With that condition, his cancer, high cholesterol and a family history of heart disease, Auldridge went shopping for health insurance last spring.
It soon became clear, he said, that insurance companies were reluctant to offer meaningful coverage to such a high-risk patient.
“They were like: ‘We don’t want to touch you. We don’t want to go anywhere near you because of your costs, ‘ ” he recalled.
“And I was like, well, thanks. But doesn’t that defeat the purpose of insurance? … Isn’t that what insurance is for, to cover my medical expenses?”
Changes take effect Jan. 1
This Wednesday, some of the most sweeping changes to come from a federal health care law passed three years ago will take effect.
Nearly all Americans must have health insurance in 2014 or pay a tax penalty, either $95 or 1 percent of their income, whichever is greater. The penalties grow substantially over the next two years.
People who had been uninsured in the past — many because they could not afford it — will have plans purchased through an online marketplace, where financial assistance is available to the low- and moderate-income.
And effective Jan. 1, the Affordable Care Act prohibits insurance companies from denying coverage to people with pre-existing conditions — a wide range of physical or mental illnesses or conditions that began before the person’s insurance plan was issued.
Insurers also can no longer cite pre-existing conditions in refusing to pay for treatment that would otherwise be covered, or to charge more because of a patient’s past medical history.
Between 50 million and 129 million Americans younger than 65 have a pre-existing condition of some kind, according to the U.S. Department of Health and Human Services.
The range is so wide because pre-existing conditions are defined differently by different insurers. Some are universal, such as heart disease and cancer. Others are less obvious: asthma, high blood pressure, diabetes, pregnancy, even an old knee injury from high school football.
In Virginia, an estimated 3.5 million people have a pre-existing condition, according to the Obama administration.
The people most likely to be denied coverage because of a previous medical problem are those enrolled in individual and small-group insurance plans, said Clare Krusing of America’s Health Insurance Plans, the national trade association for the health insurance industry.
Those with employer-based coverage are less affected, partly because the larger plans have more of a risk pool in which the premiums paid by healthy employees go toward the costs of caring for their co-workers in times of illness or injury. About 60 percent of Virginians have coverage through their employers.
When it comes to getting insurance in the individual market, a national survey by The Commonwealth Fund found that 36 percent of adults said they were turned down for coverage or charged a higher price because of a pre-existing condition.
In Virginia, 16 percent of applicants in the individual market were denied coverage this year because of previous medical problems, according to the Kaiser Family Foundation. The national rate was 18 percent.
Killer headaches and a bizarre horror show
When Nathan Auldridge went off to college in 2005, things such as brain cancer and sky-high medical bills were not on his mind.
He was thinking more about screenwriting and maybe even directing movies, selecting a major of theater with a minor in film studies.
Then, about halfway through his freshman year at JMU, came the killer headaches, double vision and vomiting to the point of dehydration.
A trip to the doctor led to an MRI, which revealed a cancerous tumor that was blocking the flow of cerebral spinal fluid into the third ventricle of Auldridge’s brain.
Faced with a life-threatening situation, the 22-year-old responded with levity.
He named his tumor Fred, partly because it was a four-letter F-word that rhymed with head and dead. And partly because it seemed easier to battle a nemesis named Fred than confront the medical conditions of ependymoma (a tumor that arises from the ependyma, a tissue of the central nervous system) and hydrocephalus (an abnormal accumulation of cerebrospinal fluid, also known as water on the brain).
In January 2006, Auldridge was sent to the Duke University Health System, where doctors performed what he calls “a bizarre sort of horror show” — a craniotomy, which entailed temporarily removing part of his skull to get to the tumor.
By the time he was released from the hospital six weeks later, the bills amounted to a horror show sequel of about $450,000.
It was Auldridge’s first lesson in the value of health insurance. Most of the costs were covered by an Anthem Blue Cross and Blue Shield plan held by his father, an administrator with the state Department of Environmental Quality in Roanoke.
When Auldridge’s father, Norman, died of a heart attack in 2007, Nathan transferred to another Anthem plan issued to his mother, a retired schoolteacher in Salem. Later, when he became too old to be covered by that policy, he spent several years skipping between a government continuation plan and employer-based coverage.
His current job, working with a Floyd County-based agency that provides home and community-based services for people with special needs, does not offer an insurance plan. It does provide a supplement to his salary to help cover the cost of a plan on the individual market.
But for someone whose medical bills and insurance premiums total nearly half of his $20,000 annual income, it’s not enough.
With help from his family, Auldridge said, he’s been able to pay his bills and cobble together a meager existence.
“I am truly blessed to come from a family that has been able to help me stay afloat throughout this whole ordeal, ” he said. “Not everyone is so fortunate.”
New plan is ‘a godsend’
Considering his many medical issues, health insurance for Auldridge is as much of a necessity as food and utilities. So when his options ran out in May, he went looking for insurance on the individual market.
The best he could find, he said, was an Anthem plan for a single 30-year-old with no dependants. It cost $483 a month and covered very little of his expenses until he met a $5,000 deductible, Auldridge said.
When Auldridge finally met his deductible earlier this month, it meant he could pay just $127 for his prescriptions — instead of the $1,403 he had been forking out each month.
But with the plan starting over on Jan. 1, he faced another $5,000 mountain of a deductible and more high premiums.
By then, though, there was an alternative. Having closely followed news reports about the Affordable Care Act, Auldridge knew that insurance companies could no longer hold his medical history against him. He also knew that his low income made him eligible for subsidized private insurance sold through a government-run marketplace.
On the website HealthCare.gov, Auldridge found a plan offered by Coventry Health Care that cost just $111 a month. Better yet, the deductible was only $1,750.
For many single people in his income bracket, the plan might look expensive, Auldridge said. “To me, it looked like a godsend.”
And it reminded him, once again, of the discrimination that he says the Affordable Care Act will abolish.
“Just the sheer audacity of an insurance company saying, you’re not profitable, so we won’t insure you, ” Auldridge said. “We wouldn’t make money, so we don’t want to cover your medical expenses.”
Anthem spokesman Scott Golden confirmed that Auldridge had a plan with the insurance company. But he said he could not comment on Anthem’s underwriting policies. Underwriting is the insurance term for using someone’s medical history in evaluating them for coverage.
Stabilizing premiums
In the politicized world that health care has come to inhabit, there has been much criticism in recent months of the Affordable Care Act.
The Oct. 1 rollout of HealthCare.gov was plagued by technical problems. And President Barack Obama’s often-repeated promise of “If you like your health insurance, you can keep it” was shown to be false with the cancellation of millions of plans that did not meet the new law’s tougher requirements for coverage.
Less controversial, it seems, is the idea that sick people should not be denied coverage just because they are sick.
“I would say that probably most Americans believe that people with pre-existing conditions should be covered, ” said Timothy Jost, a Washington and Lee University law professor who is considered an expert on the health care law.
“But by no means do all of them, ” he added.
Earlier this year, the Virginia director of Americans for Prosperity, a conservative advocacy group, said that covering everyone with a pre-existing conditions will drive up costs for all consumers.
“Insurance companies and government will now have to pay for expensive procedures for folks who didn’t have coverage, ” Dave Schwartz said. “There’s not going to be enough people [in the insurance pool] to make up for that.”
Schwartz is no longer head of the state AFP chapter. The new director did not respond last week to a call and email seeking comment.
In an effort to stabilize premiums during the law’s first three years of implementation, the Affordable Care Act will levy what amounts to a $63 per enrollee fee for health plans.
The fees, which will start in 2014 and decline over the next two years, are expected to raise $25 billion — money that is needed to shore up the system until enough people have purchased insurance to meet the higher costs of covering those with pre-existing conditions.
The fees will amount to millions of dollars for large employers, with much of the cost expected to be passed on to employees in the form of higher premiums.
“It’s not going to be a gift, ” Jost said of the expanded coverage.
However, the Department of Health and Human Services estimates the program will reduce premiums in the individual market next year by 10 percent to 15 percent of what they would have been otherwise.
Other methods to cover the Affordable Care Act’s estimated cost of about $700 billion over the next five years include higher Medicare taxes for the rich, taxes on medical devices, higher fees for the insurance and pharmaceutical industries, and penalties that take effect in 2015 for large employers that don’t offer health insurance to their employees.
In the long run, whether the system is financially sustainable will depend on how many of the uninsured sign up for coverage. Premiums paid by young and healthy people, in particular, are needed to offset the costs of paying for the ill and elderly.
‘Not a leech’
Like the cancer that is now in remission, Nathan Auldridge is hoping that his financial burdens will soon fade away.
In recent years, he’s spent about 40 percent of his income on medical bills and insurance premiums. He expects that to decline to about 15 percent with the cheaper and better coverage the new year will bring.
He’s looking forward to contributing more to the local economy, patronizing restaurants and stores that in the past were too much of a drain on his credit card.
As for getting a break from the government on his health care costs, Auldridge feels no shame. “I work, ” he said. “I’m not a leech. I’m not trying to mooch off the system.”
Somewhere along the way to becoming a cancer survivor, Auldridge began to develop strong political beliefs.
He is the chairman of the Salem Democratic Committee and has organized rallies in support of health care reform.
But rather than being a partisan cheerleader for the Affordable Care Act, Auldridge sees himself as just one of the millions of people the law seeks to help.
And if his personal experiences shaped his political beliefs, so be it.
Auldridge still remembers the thrill he felt when Sen. Barack Obama of Illinois, then running for president, visited James Madison University in October 2008.
After landing a job as an usher at the event, Auldridge got close enough to shake the candidate’s hand and speak to him briefly.
He recalls telling Obama about the costs of his cancer, and urging him to follow up on a campaign promise to reform the nation’s health care system.
Obama replied: “I’ll do it.”