A young man I know who is 25 finds himself in a health insurance pickle. The much-touted provision of the new reform law that lets young adults stay on his parents’ insurance policy is no help, leaving him with the choice of very costly insurance or going without.
Matt had heard about the new law and checked in with his parents, both retired federal employees. Neither is covered by Medicare. That’s good because young adults whose parents are on Medicare are out of luck. Matt’s parents get their retiree coverage from the Federal Employees Health Benefits Program (FEHBP), and it turns out that young adults are eligible under the new law to be added to their parents’ FEHBP plans.
But there’s a catch. Even though the reform law says they have a right to coverage as of September 23, 2010, the law governing THE FEHBP says young adults cannot get FEHBP coverage until January 1, 2011 when a new plan year begins. There’s a chance Congress may change the law when it returns from recess, but no guarantee. Matt turns 26 in May. Is it worth it to enroll? What does he do in the meantime?
He’s between jobs, having left a PhD engineering course to become a math teacher. A year from now when he is employed by a school district, he’ll no doubt have insurance, but that can be an eternity if something goes wrong. He had insurance as a grad student and researcher but was not eligible for COBRA. He says he couldn’t afford it anyway.
Bard College, where he is earning a master’s degree through the Math for America program, does offer students insurance. Like a lot of university insurance plans, though, it doesn’t cover much. I looked at it and think that no one who wants good coverage would be helped by this plan. The policy disclosed up front that it was intended to supplement a student’s other medical coverage and cover things the main insurance did not. But that’s not useful if you have no other insurance.
The college’s limited benefits policy offers basic accident benefits up to $1,000. It also pays a dismemberment benefit caused by an accident—for instance, up to $1,500 if he loses one hand and one foot or one hand and the sight of one eye. Not a lot of compensation there. Sickness benefits are similarly skimpy—a maximum of $750 for hospital care and a maximum of $1,000 if he needs surgery. The insurer will pay up to $60 per day for the physician services if he lands in the hospital.
It’s not hard to see why he’s declining the coverage.
Matt next investigated Healthy New York, a state program designed to help poor people buy insurance. The coverage is decent enough with premiums in the $200 to $300 range for individuals if they qualify. However, his income is a few hundred dollars too much. The state website I looked at says his monthly gross income cannot exceed $2,257. The rules also say that his current employer (presumably Bard College) cannot offer coverage. It does. Sort of. Does that disqualify him?
The Healthy New York website says that even if he has a limited benefits policy, he might qualify anyway if the policy is not comprehensive. According to the state, that means “it includes only medical benefits or only hospital benefits, but not both.” The Bard policy offers skimpy benefits for both. Another strike here?
His last option is an individual policy offered by a commercial insurance company. In New York, anyone can get a policy even if they have serious health problems. Matt has none. The New York State Insurance Department says that premiums for an HMO, the least expensive choice, would range from $752 to $2,544 each month. Even the lowest amount is a hefty percentage of his monthly salary. If he doesn’t buy coverage, his last option is to seek care at one of the community clinics in the city that will treat him and ask him to pay on a sliding scale based on his income.
Matt wants to have coverage. He does not fit the insurance company stereotype of a dare devil or thrill seeker, willing to take chances. He is simply another petitioner to a health insurance system that, despite the recent drive toward universal coverage, still leaves Matt and people like him falling through the cracks.
Delivering evidence-based medicine is a deceptively elegant and simple goal. But new findings about the increase in antibiotic resistance challenge us to consider just how complicated and challenging it is to actually define and deliver evidence-based care. 
Aftershock:
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