I wrote about Nathan Wilkes and his son Thomas last year, when the family was facing the imminent prospect of hitting the cap on their health insurance. Thomas was born with hemophilia and later developed a resistance to treatment. $1 million doesn’t go very far in his case, and that was the lifetime maximum on Nathan’s employer-provided health insurance policy.
The family is back in the news again, now that Thomas is on Cover Colorado. But Cover Colorado also has a $1 million lifetime maximum, and it’s the policy of last resort for Colorado residents with serious illnesses. What will Nathan and his wife do once Thomas hits the policy cap on Cover Colorado? And with the severity of their son’s illness, that’s a when, not an if. They have even talked about getting a divorce so that Thomas would qualify for Medicaid.
To make matters worse, the family took an $80,000 hit while they were between policies for Nathan. Cover Colorado requires applications to be submitted by the 15th of the month in order to begin coverage the next month. And you can’t have Cover Colorado in place simultaneously with another health insurance policy. And in order to qualify for Cover Colorado, Thomas had to meet the policy cap on Nathan’s group policy. So there was an unavoidable period of at least two weeks where Nathan had no health insurance. Now the Wilkes family is on the hook for the $80,000 in treatment costs that Thomas incurred during that time. They did everything they could to avoid a gap in coverage and pin down the exact timing of when Thomas reached his policy maximum. But United HealthCare was unable to provide up-to-the-minute claims details, and the uninsured expenses occured despite the family’s best efforts. In my own experience, I usually find that the claims data I get over the phone for our family and our clients is at least two weeks old, and the most recent visits are never included in the summary the health insurance company is able to provide for me. I cannot imagine trying to pinpoint reaching a $1 million policy maximum with any degree of accuracy. It does seem absurd that in 2008, when data of any sort can be transferred around the world with the click of a mouse, there is still such a lag time in the processing and updating of health insurance claims. The Wilkes family jumped through all the right hoops and still ended up with $80,000 in unpaid medical bills during their son’s transition from United HealthCare to Cover Colorado. Obviously we need a faster, more streamlined process in Colorado for getting people switched over from private health insurance to Cover Colorado when the need arises.
I wonder what will be next for this family? Will we see another news story next year, detailing how Nathan and his wife have filed for divorce in order to be able to obtain Medicaid for Thomas? Perhaps Nathan will quit his job and take a lower-paying one so that they can qualify for SCHIP. I realize that anecdotes are not statistical data. And the story of one family’s struggles with health insurance, regardless of how compelling that story may be, is indeed an anecdote. But I challenge anyone who believes that our health care and health insurance systems are not broken, to come up with a workable free-market solution for the Wilkes family.