Why Am I Paying More Under the Affordable Care Act?

Mr. President,

You don't know me. Why should you? I'm just one of those many Americans who purchased a health care plan under the Affordable Care Act -- and it's not going terribly well. I want you to know that I voted for you. Twice. I'd probably vote for you a third time if that was even possible. So, anything I say isn't personal. As in, I don't hold you personally responsible for what's going on in my life, but as a citizen in your country, I'd love you to know what's happening at ground level. For people like me, who bought insurance through the Affordable Care Act. And. It's a mess. A crazy frustrating mess.

Let me back up, I was born in England to an American father -- dual citizenship. It's a blessing. And I grew up in a country where health care is something I never had to worry about. You get sick. You see a doctor. You go to the pharmacy. Get some pills. Or. Go to the hospital. It's not perfect. I'll admit that, too -- but at least anyone who needs treatment gets it. I've never had to think about finances before going to see a doctor -- I would just go.

When I moved to America, five years ago, I got shot. The 'event' happened in West Hollywood, hardly a noted area of town with featured violent crime, and I'd only lived in the country 42 days. I wrote about it for the Guardian newspaper (you can read about it here). No one in America was at all interested in a sniper shooting at random people in a built-up area. Strange. But true. I tried to alert media outlets. No one cared.

After I got shot, I tried to get in an ambulance but they wouldn't take me, as I didn't have insurance. I had to flag down a car to take me to Cedars Sinai ER. Then, when I got to the hospital, no one would treat me until I gave them my credit card and, while I could go into the inefficiency of the police, the lack of interest in my shooting by the media and the pain of having a bullet removed from my back, the main thing that stands out is the fact that I was refused treatment until they swiped my credit card. Welcome to America.

After my first year in the States, I bought an Anthem Blue Cross insurance plan. It had a $2,500 deductible, cost about $130 a month and I never used it. Due to the deductible, it was always cheaper to just pay cash. And, when they discovered a shadow on my breast during my first routine scan (which was free through my Blue Cross insurance), during my follow-up appointment six months later I discovered that I wasn't covered by my insurance -- even though it proved to be just a shadow... it was viewed as a "pre-existing condition." As a result, during the time I had the Anthem Blue Cross Insurance Plan, I always get asked to pay for it - even though it was just a shadow and nothing was wrong. Thanks Blue Cross... so... when Covered California and Obamacare sailed into harbor, I was on board.

I bought a plan -- a Blue Shield Enhanced PPO, with a $2,000 deductible. My costs were jacked up to around $317 a month, which included dental care. It came into effect on January 1st. I'm efficient and organized. I made sure I signed up the MOMENT I could. And, I was excited.

On December 31st, I was paralyzed -- I could barely move and was in massive lower pain agony. My friend drove me to a doctor -- and when they punched in my Anthem Blue Cross details it said that my insurance had been cancelled (even though I'd paid until the end of the month). So I paid in cash. Saw the doctor. And spent the next three days 'enjoying' a cocktail of Flexeril, Ambien and Xanaflex. I started having PT two weeks later, my insurance paid a percentage of that, I began to get excited about my new Blue Shield PPO. As I wasn't getting better, I got an MRI. The results were pretty conclusive:

"At L4-L5, there is a large left paracentral disc herniation with an acute annular tear, measuring 7.5 mm in anterior-posterior dimension by 14 mm in transverse dimension by 9 mm in craniocaudal dimension. It has caused severe central canal stenosis and severe left lateral recess narrowing with mass effect on the traversing left L5 nerve root. There is mild to moderate bilateral neural foraminal narrowing. Mild hypertrophic facet degenerative changes are present." (Emphasis mine.)

I didn't know what all that meant. This was all medical jargon beyond my knowledge BUT I knew that the words "acute" and severe" meant that it was bad. And it was time to consult a surgeon.

Here's what I discovered. Many surgeons have opted out of Covered California. In fact, it appears that Blue Shield of California now has about 40 percent fewer physicians and 25 percent fewer hospitals in its network than last year. Though the hospitals and surgeons had until March 31st, it appears that many of the doctors have refused to renew their contract with Blue Cross and Blue Shield. That meant that I couldn't see a number of doctors unless I paid for them... so I did.

I paid a fee to a doctor who was recommended by my chiropractor, who was viewed as a conservative surgeon. He liked to avoid surgery if possible. He cost $450 for a 15-minute consultation where I spent most of it in tears. He looked at the MRI and put me forward for a cortisone epidural. He asked me: "How would you feel if I told you I'd probably need to operate?" I replied: "I'd seek a second opinion." He looked at me sadly and putted my shoulder: "Honey. I am the second opinion." However, we went ahead with the epidural. Blue Shield take up to a week to approve epidurals. I needed one immediately. So. I paid cash. I was $1,000 out. And... It didn't work. Maybe I had about 30 percent relief... but then... after a few days. It was agony. I was scheduled for a second one but I didn't hold out much hope.

I spent the next four days on the telephone. I called Blue Shield. I was on hold four two hours. My phone died. I went online. And started calling all the surgeons I could find IN NETWORK, who were covered by my insurance. I knew nothing about them, just that they took Blue Shield. Well... they took my insurance. Correct. Just as it said on the website. BUT, of the surgeons I called, 100 percent of them didn't operate out of a hospital that took my insurance.

So. I looked at the hospitals that DID take my insurance. I called them. Asked them to give me a list of doctors who had operating privileges at those hospitals. They wouldn't. I was (and am) in pain. And no one could help me. Some expressed sympathy. They told me: "I'm so sorry -- it's all just so new, you're a victim of the changes, no one knows what they're doing." That wasn't terribly reassuring. I've never been a victim, even after I was shot and conducted my own investigation into my shooting... I didn't get any answers but still tried to do my best to get them.

Five years later. Here I am again. Investigating. While I was making my calls, I got an insurance broker on the phone, and he confirmed that even medical facilities that WERE taking Blue Shield PPOs were REFUSING to take any Covered California's PPOs because they felt they wouldn't get their money. Despite the fact that a 'regular' PPO bought through Blue Shield directly was the same as a Covered California PPO. It seems they are discriminating against my PPO and now, I am, officially a victim of the new system.

I found a woman at a doctor's surgery in the finance department - I asked her to suggest some doctors who operated at the few hospitals I had coverage. She gave me five names. I called them. I made appointments with them. No one would agree to give me any costs until I saw them in person. So... I stumped up $350 for one doctor, $400 for another, $450 for a third. I saw six doctors and made 38 phone calls across Los Angeles, the San Fernando Valley and Orange County. If there's one thing I know how to do, it's practice due diligence.

And then... I started negotiating with them for a cash price for my surgery. Prices ranged from $4,000 through to $20,000. None of them were covered by my insurance and, some of them no longer had operating privileges at the hospitals I needed OR they didn't bill the insurance through the hospital, which meant I was in danger of paying for everything -- surgery and the hospital. It has been like a horrible game of UNO, matching doctors with hospitals, who would include the anesthetist, and who would be covered by my insurance.

By this stage, I was already over $4,000 out of pocket (MRI, meds and doctors appointments) -- and still, no real answers. I'm still in pain. Still suffering. So, after all my doctor's appointments, I booked three surgeries booked with three different surgeons at three different locations. All these were leading back surgeons, I knew people who'd had surgery with them, and then started going back and forth between them all, haggling for costs for between them to find the best price. It was my health -- maybe I could have gone for a cheap option but I was concerned about this surgery. It's my back. It involves my spine. I wanted the best I could possibly find.

It was suggested I fly back to the UK and have my surgery there. I felt that wasn't a solution -- I'm an American. I should be entitled to American health care...

My physical therapy office told me they would no longer accept my insurance as they were only getting $15 on top of the $45 I was paying as a co-pay. It wasn't enough. So, I had to stop my PT until I could find a new place that DID take my insurance.

Meanwhile, I had surgery on March 18th. I'm paying around $10,000 for it. I'm not happy about it. But, they did it at a hospital I DO have coverage at, and after my $2,000 deductible, and all the costs so far, I will have paid $16,000 -- at least -- in out of pocket expenses for a routine lower back surgery. I was grateful for a few things at this stage -- when I got to the hospital -- I had to pay a fee BUT they waived the deductible in this case. Plus, as I chose an in network hospital, the surgery was cheaper there than, say, Cedars Sinai. Also, thankfully, my experience during my actual surgery at St. John's Hospital was amazing -- from all the nurses to the staff there -- I couldn't have found a more accommodating hospital so, I'm truly thankful that they take Blue Shield PPOs.

To summarize, this is what I've found going on at the grassroots level:

a) Doctors are not renewing with Blue Shield/Blue Cross so they don't take the insurance.

b) Hospitals (except for a few) will not take my insurance with Blue Shield/Blue Cross.

c) Doctors who DO take Blue Shield/Blue Cross don't operate at hospitals covered by the insurance.

d) No one is available to answer basic health care questions.

e) Hospitals/doctors who DO take Blue Shield/Blue Cross won't take it if it came through Covered California.

f) It's a mess.

I'm not alone.

I'm just hoping something is done. And soon. I'm exhausted. Tired. And in pain. I'm getting a couple of credit cards to cover my costs. But I believe in America. Though I don't believe that affordable health care should be denied. I want to say that I do believe in Obamacare -- I think it's something that could work and I want it to work -- but it just appears, to this lay person anyway, that some of the institutions already in existence are making it incredibly challenging for citizens to get the treatment they need and deserve. Providers can't be forced to accept the new insurance but... I wish they would.