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Caught in the gap: How Washington residents are navigating health coverage in the midst of a pandemic

UPDATED: Tue., Nov. 24, 2020

Mary and Raymond Clark couldn’t afford health insurance through the state benefit exchange, and Raymond cannot get it through his job. The couple qualified for a nonprofit program called Project Access Northwest for health insurance benefits after a heart attack sent him to the hospital a couple of years ago. (DAN PELLE/THE SPOKESMAN-REVIEW)
Mary and Raymond Clark couldn’t afford health insurance through the state benefit exchange, and Raymond cannot get it through his job. The couple qualified for a nonprofit program called Project Access Northwest for health insurance benefits after a heart attack sent him to the hospital a couple of years ago. (DAN PELLE/THE SPOKESMAN-REVIEW)

Raymond and Mary Clark knew they were taking a gamble when they moved to Spokane in 2016.

The Clarks were moving from Oregon and lost their health insurance coverage .

Raymond started a new job that offered no health benefits, and plans offered on the Health Benefit Exchange in Washington were too expensive for the couple to afford alongside bills and house payments.

The Clarks are still a few years away from retirement. Raymond will turn 65 and qualify for Medicare in a couple of years, but Mary is a few years younger. They do not qualify for Medicaid coverage in Washington but also could not afford a plan on the Exchange, leaving them, like many others in the state, in limbo.

In summer 2018, Raymond started to have chest pains. In August, they got so bad, he had Mary drive him to the hospital. It was a heart attack – a serious one – that left him with two stents and more than $100,000 in medical bills, he said.

The couple knew they couldn’t afford to keep the house if they had to pay off those debts out of pocket.

“If you didn’t have a heart attack going in there, you certainly would have afterwards getting the bill,” Mary said.

But then they were referred by Providence Sacred Heart Medical Center to a program called Project Access Northwest, a nonprofit that helps uninsured Washington residents get access to medical care.

The Clarks qualified for the premium assistance program through Project Access, which enables patients to enroll in an insurance plan without having to pay monthly premiums.

To qualify, patients have to be referred by the hospital that pays for the plan along with donations to the nonprofit. Participants must live at or below 300% of the federal poverty level and file taxes in the U.S. Additionally, these patients do not qualify for Medicaid or Medicare but also can’t afford plans on the Exchange, placing them in what is sometimes referred to as the “Medicaid Gap.”

“We help enroll them, and the hospitals give them funds to enroll them in a Silver level plan, which is the most bang for the buck, so hospitals pay for those plans, and so they are invested in it all year,” said Melissa Johnson, deputy executive director of Project Access .

Raymond was in the hospital for four days. Toward the end of his stay, the Clarks were referred to the program and enrolled. The plan they selected retroactively covered the Clarks, covering the lion’s share of their expenses.

“Otherwise we would have had to sell the house, no doubt,” Mary said.

Ray changed his diet, began exercising more frequently and lowered his cholesterol. He returned to work the week after his hospital stay. Mary was able to begin physical therapy for her degenerative disc disease, as well as visit a pain clinic and change her eyeglass prescription for the first time in a few years.

Then in March 2019, Ray started to get chest pains again. In what felt like a déjà vu moment for the Clarks, he was rushed to the hospital for another heart attack and got another stent. Something didn’t seem right this time, however.

Despite all his work to adjust his lifestyle and keep his heart healthy, he’d had another heart attack.

With his health coverage, Ray finally saw a specialist who figured out an unusual issue that might be causing Ray’s problems. He has high levels of lipoprotein-A, which is associated with coronary heart disease. Ray was put on new medicine to help address this specifically.

“The medicine helps stop the blockage and break up the proteins and the fats, platelets and things that plug you up,” he said.

The couple was renewed for health coverage through the program in late fall 2018 and 2019 as well . The program covers the premium payments for a Silver plan through the Health Benefit Exchange that families get to choose, but the Clarks are still on the hook for copays for visits and medication costs.

Addressing the gap

The coronavirus pandemic has led many families to reevaluate or consider seeking health coverage, while in the past they might not have sought it out at all.

With no federal penalty for not having health insurance, the uninsured rate in Washington had been inching up in 2018 and 2019. The pandemic meant a dramatic increase in the number of uninsured Washington residents.

In January , 6.7% of Washington residents were uninsured. By mid-May, 13%, or more than 1 million Washington residents, had lost or did not have insurance. As of mid-October, 7.2% of Washington residents are still uninsured.

This is largely due to the loss of many people’s health coverage tied to their employment, according to data from the Office of Financial Management.

Depending on a family or individual’s income, they might qualify for Apple Health, the state’s Medicaid program, for which enrollment has grown steadily throughout the pandemic. Since April 1, between 6,000 and 6,500 Washington residents have signed up for Apple Health each week.

In Spokane County, Better Health Together, the region’s Medicaid accountable community of health, has seen a spike in demand for Apple Health enrollment throughout the pandemic.

About 94% of the Inland Northwest region’s enrollment from March to September was for Apple Health, said Alison Poulsen, executive director of Better Health Together.

“We continue to get a lot of calls from people who have skipped on insurance previously because it was too expensive, but now they are nervous,” Poulsen said.

In Spokane County, the uninsured rate has stabilized after a volatile time of unemployment earlier this year. Before the pandemic, the uninsured rate in the county was 5.3%, and after a spike this summer, the rate returned to 5.3% by October.

New public options

Open enrollment for health care coverage offered on the state insurance exchange began this month and runs through Dec. 15, for coverage that takes effect in January .

This year Washington state is forging ahead with a new public option subset of plans offered on the exchange after passing landmark legislation to offer standardized plans in 2019.

The Health Benefit Exchange began the procurement process for health insurance companies to offer Cascade Care plans early in 2020. Then the pandemic hit.

COVID-19 had a significant impact on the willingness and ability for some insurers to participate in the program, said Michael Marchand, chief marketing officer at the Exchange, especially with the uncertainty that the virus brought early in 2020.

There are five insurance companies offering Cascade Care public option plans in 19 counties statewide.

“I feel really happy and pleased we’re able to deliver five carriers,” Marchand said.

The plans have what is called a “standard benefit design,” meaning they will have similar copays and deductibles, as well as plans that cover more services, like primary care, mental health services and generic prescription coverage, before having to meet the deductible.

While getting Cascade Care plans to the finish line was an accomplishment, Marchand acknowledged that it might take a few years for the market to stabilize around a midpoint and drive prices down to a more affordable level.

“What we saw this year was insurance carriers being very conservative to a certain extent in terms of what their offerings were, at least in terms of public options,” Marchand said.

State Sen. David Frockt, one of the architects of Cascade Care, acknowledged that the COVID crisis made it challenging for some providers to participate in the program. He said some larger hospital systems also would not contract under the public option framework.

And while the initial plan offerings might not have been as bountiful or at the price point imagined, Frockt said the legislation that authorized Cascade Care in the first place ended the way it did in order to become law.

“I think we did everything and got everything out of this particular bill we could have to get it to pass,” he said.

Ultimately, driving down health care costs for Washington residents remains the focus for Frockt.

“The biggest complaint from my constituents in the marketplace is, ‘I’m paying a ton of money for my family and myself,’ ” he said.

Part of the legislation that authorized the public option plans also included a subsidy study that could address the many Washington families and residents that find themselves, like the Clarks, in a financial position where they cannot afford Exchange plans even if they want them. The study, published this month, outlined what lawmakers could do to offer premium subsidies for residents with incomes up to 500% of the federal poverty level.

“I think we still have way too many gaps,” Frockt said, noting something as simple as losing one’s job can put an entire family into the ‘uninsured’ category.

Health plan enrollment up

Despite the chaos the pandemic has brought to the health care and health insurance industries, Washington residents seem to be taking open enrollment seriously this year.

More Washington residents are enrolling in health insurance plans on the state marketplace than this time last year, according to a news release from the Washington Health Plan Finder.

As of Nov. 16, more than 188,000 Washington residents have signed up for health plans, including more than 6,000 first-time enrollees, according to data from the Washington Health Plan Finder.

So far, Cascade Care plans make up 36% of plans selected.

The Project Access premium assistance program offered to the Clarks and 678 other Washington residents since 2014 enables them to enroll in their choice of silver plan on the Exchange, but they are up for renewal each year, subject to funding and demand.

This year, the Clarks were worried about getting approved again, due to the influx of need brought on by the pandemic.

Earlier this month, Mary got the call that they were approved.

“We were very, very relieved, to say the least,” she said.

The Clarks acknowledge that they are lucky having been referred to Project Access and continuing to access coverage that way.

In the nearly two years when the couple did not have health coverage, it could be stressful, Mary said, knowing that they might have to choose at some point among paying a bill or their mortgage and their health care.

“It’s like, well, you know, do I get sick? Do I not get sick? The cost (of health insurance) was just exorbitant, quite frankly,” she said. “And I’m sure we’re not the only folks in this position.”

This story has been updated to reflect the most recent number of people enrolled by Project Access in the premium assistance program.

Arielle Dreher's reporting for The Spokesman-Review is funded in part by Report for America and by members of the Spokane community. This story can be republished by other organizations for free under a Creative Commons license. For more information on this, please contact our newspaper’s managing editor.

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