Fairness of insurance caps is questioned

"Worrying about bills, that just makes you sicker," said leukemia patient Karlin Brockington.
"Worrying about bills, that just makes you sicker," said leukemia patient Karlin Brockington.

Most employer-based insurance plans have lifetime caps limiting how much can be spent per person. Many appear to be reaching those caps. Just ask Karlin Brockington.

Posted: December 15, 2008

In May 2007, Karlin Brockington was really looking forward to vacation from her job as assistant manager of Sam Goody at the Deptford Mall.

"I needed a rest," said Brockington, now 44. "This was the first time I felt like I was getting older, that I needed to slow down, that I needed to get out of retail because these kids were driving me crazy."

Her problem wasn't kids or retail.

On May 19, "I was on the floor, doing my work, and I couldn't move," she recalled. "I was like having an out-of-body experience."

An employee walked past, and "I couldn't even talk to him. I wanted to tell him, 'Would you please help me?' "

She dragged herself home to Lawnside and into bed.

The next morning, her friend and manager, Cheryl Monaco, "told me to go to the hospital because in the 15 years she's known me, I've never been sick. She said go or she was going to call my mother."

Brockington went to Cooper University Hospital - for 48 days.

Acute myeloid leukemia.

Brockington had been paying $19 a week from her paycheck for health insurance.

For 16 months, insurance covered chemotherapy, a bone marrow transplant, five months in hospitals.

But on Aug. 28, 2008, a letter came from her plan administrator. Brockington had reached her "lifetime maximum coverage of $2 million."

In five days, she would be uninsured.

"I started freaking out," Brockington recalled. "We started working on my options, what I could do, and there wasn't a whole lot."

More than half of all employer-based insurance plans in America have lifetime caps limiting how much can be spent on any one employee, according to a Kaiser Family Foundation survey.

Because of rising health-care costs, more Americans appear to be reaching those caps, even though cases are still rare. Insurance companies and employers say by capping lifetime expenses for any one employee, they can afford better benefits to all employees.

"The primary reason for . . . caps is to lower the cost of insurance so employers can cover as many people as possible," said Mary McElrath-Jones, spokeswoman for UnitedHealthcare, parent company of UMR, administrator of Brockington's health plan.

Many find caps to be unfair.

"What insurance is supposed to do best is handle the extraordinary thing that is rare," said Gary Claxton, health policy expert at the Kaiser Family Foundation. "So to some extent, these policies are not protecting the people who most need insurance. These people did everything they were supposed to do. They were paying their premiums. Insurance companies are finding ways to limit exposure of these policies to really sick people."

The 2007 Kaiser survey found that 32 percent of companies set caps at $2 million or more. But with today's health-care costs, $2 million isn't what it used to be.

People in need of organ transplants, or with rare blood diseases, chronic illnesses, or cancers that require expensive therapies tend to be most likely to hit a lifetime cap.

Rick Lofgren, president of the Children's Organ Transplant Association, said, "we're seeing more patients anecdotally that are hitting caps, and we're seeing unfortunately more caps that are being dropped as low as $250,000.

"For most patients, that doesn't get them out of the hospital following a transplant . . . I'm seeing that as a bigger concern."

Beth Darnley, the chief program officer for the Patient Advocate Foundation, a nonprofit that helps 44,000 Americans a year without insurance, said "layers of caps" are causing more problems for patients - caps on the number of visits, the amount spent per incident and per year, as well as lifetime limits. "Now you're subject to four different caps, and that is very prohibitive for patients," she said.

Darnley recognizes the bind that employers are in. If they cover those in greatest need, they risk not insuring other employees. "I can't even make a moral judgment on that," she said.

When Brockington was diagnosed and couldn't work, she lost her job. But her employer, Trans World Entertainment, which owned the Sam Goody store, kept her on insurance for several months.

When it would no longer carry her, she started paying $278 a month under COBRA, a federal law that allows workers to continue their health insurance up to 18 months.

It was after 10 months on COBRA that Brockington got her letter, telling her she had reached the lifetime limit.

Without insurance, she has been scrambling.

Even in remission, she still needs considerable health care. On Tuesday, she had a bone marrow biopsy to confirm she is cancer-free.

This fall she's had two cases of shingles and one of vertigo, in part because her immune system is still weak.

"She's definitely half the person that she was," said Monaco, who's also out of work and getting covered through COBRA. Their Sam Goody store in Deptford closed in January. "She was fun-loving, teasing, outgoing, funny, and it's pretty heartbreaking to see what's happened to her. But she seems to be coming back."

In November 2007, Brockington was approved for Social Security disability, and began receiving $944 a month.

But that disability income is eaten by co-pays, living expenses, car insurance.

She will be eligible for Medicare - but not until next November. When Congress extended Medicare to include the disabled in 1972, it imposed a two-year wait, which still exists today.

Brockington then tried to get Medicaid, medical coverage for the poor. She applied in New Jersey, but because she owns a mobile home in Delaware, and is licensed to drive there, New Jersey told her to apply there, she said.

Delaware officials, she said, told her that with a $944 disability income, she earns too much to qualify for Medicaid. She plans to apply again soon in New Jersey under a program called Ticket to Work. She has been living in Lawnside for years with her mother and sister - commuting to work in Deptford long before she got sick.

She cannot afford to buy private insurance.

Brockington has spent all her savings - $10,000 - since she lost her insurance.

Now she is more than $16,000 in debt, she said, and a collection agent - very pleasant - called Wednesday about a $2,400 medical bill.

Thomas Jefferson University Hospital, where she had her bone marrow transplant, continues to give her the care she needs - including Tuesday's biopsy - although she continues to get bills. Jefferson will give her some level of charity care if her Medicaid applications are rejected, their executives said.

"Nobody should lose their health insurance," she said the other day, sitting under a blanket in Lawnside. "There should be something else you should be able to get. So this is something you don't have to worry about when you get sick. Worrying about bills, that just makes you sicker."


What Went Wrong

Karlin Brockington, 44, was working and paying each month for her health insurance like millions of Americans. In May 2007, she was diagnosed with leukemia. By September 2008, after a bone-marrow transplant and other costly treatments, she reached the $2 million lifetime limit on her policy.

Then she lost her health insurance.

Even though she's in remission, Brockington still needs significant medical care. She has been scrambling since Labor Day, spending the last dollar of her savings and accumulating medical bills topping $16,000.


Contact staff writer Michael Vitez at 215-854-5639 or mvitez@phillynews.com.

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