In late 2015, Andy Edgerton was diagnosed with metastatic stage four pancreatic cancer. His doctor gave him three to six months to live.
But he started a new chemotherapy treatment and responded well to it, and in mid-2017, he’s still here. “I’m fighting every day,” says Edgerton, 39, a father of two who lives in Kansas City, MO. “Pancreatic cancer is terminal, so it’s really about extension of life. The game plan is, ‘Can we extend your life with all of these immune therapies?’”
Currently he’s on a different chemotherapy regimen with rougher side effects. The treatments are expensive, and he called his insurer to make sure everything was still covered.
That’s when he learned that his insurer—Blue Cross Blue Shield of Kansas City—was dropping him. In fact, they were dropping everyone, pulling out of all individual Affordable Care Act plans in the Kansas City area in 2018.
“I’ll be cut off in January,” Edgerton says. “And I will then no longer be able to purchase any Blue Cross Blue Shield products because of my pre-existing condition.”
Andy Edgerton undergoing cancer treatment in December 2016.
Blue KC made the announcement that they were leaving the market in late May. “Like many other health insurers across the country, we have been faced with challenges in this market,” said Danette Wilson, President and CEO of Blue KC, in the press release. “Through 2016, we have lost more than $100 million. This is unsustainable for our company.”
The company’s exit left 25 Missouri counties with no insurance provider on the ACA exchanges and many people pointing at the failure of Obamacare. But not everyone believes Blue KC’s departure is a system failure—at least, not the current system
“In the last few months, insurers that have announced that they’re leaving the marketplace have pointed to the uncertainty going forward,” says Karen Pollitz, a senior fellow for the Kaiser Family Foundation. “About what the rules are going to be.”
In particular, she says, insurers are concerned that the government will stop enforcing the individual mandate requiring people to purchase insurance, allowing people to go without coverage until they get sick and then requiring companies to provide a policy—an unsustainable financial model. Companies are also worried that the government will stop reimbursing insurance companies for subsidies.
“The Trump administration is saying they’re not going to make those payments anymore, o r they may not make those payments in the future, and that could cost insurers across the country in excess of $10 billion,” Pollitz says. “That level of uncertainty has made many insurers nervous. When Anthem pulled out in Ohio and Indiana, they specifically said, ‘This is a problem, and we don’t know how to price policies for 2018 if we don’t know what these foundational rules are going to be.’”
Even insurers that have filed applications to offer policies on the ACA marketplace are hedging their bets, filing dual sets of rates or contingent rates. If the government stops reimbursing for subsidies, their rates will be 30% to 40% higher. “All that have filed applications are reserving the right to not sign the final agreement in September,” Pollitz says. “There’s still uncertainty everywhere.”
Without an ACA insurer available, those who don’t have insurance coverage through a group pol icy or an employer must shop the individual market. “They can look for policies that may be for sale off the marketplace, but they won’t be able to use their subsidies for those policies,” Pollitz says. “For most of those enrollees, that would make coverage unaffordable.”
That’s a big concern for Edgerton, who can’t work due to cancer treatment and is on disability. He’s divorced, so insurance through a spouse isn’t possible. “Even if I did work, it’s hard to find jobs I can do with cancer, that would allow the flexibility to make any type of income,” he says. “I basically am unreliable to everybody. I don’t know when I’m going to have a bad day, and I do have them.”
Recently a friend accompanied Edgerton to a treatment and casually asked the nurse how much one dose of chemotherapy cost. “She said, ‘I have no idea, let me go check,’” Edgerton sa ys. “She came back and said, ‘It’s $16,500.’”
He doesn’t blame Blue KC for pulling out of the market, but that doesn’t make his situation more palatable. “They told me it was a business decision,” Edgerton says. “My life isn’t profitable. They’re not going to insure me because it costs $40 trillion a day, but it’s repugnant how they’re doing it.”
For people like Edgerton who are losing their coverage, Pollitz suggests checking their policies to see if their contracts include a conversion right. “You might be able to convert the policy and continue it,” she says. “ that’s still not going to help with the subsidy.”
In late June, health insurer Centene announced that it will offer coverage in 40 Missouri counties next year, including the counties that weren’t expected to be covered by any other health insurers. It remains to be seen whe ther other insurers will follow suit.
“Some carriers have seen this as an opportunity to move in and gain more market share,” Pollitz says.
Meanwhile, Edgerton is trying to raise money both for treatments and to see his children, who live with their mother in Argentina. His doctors won’t allow him to travel, so he must fly his children—ages 2 and 4—to see him in Missouri. Finding new health coverage is just one more item on his to-do list.
“It just adds another layer of something to deal with, the uncertainty for me,” Edgerton says. “I don’t know what’s going to happen.”