Self-Employed Californian Shares His Coverage Story

A self-employed professional (“Bill”) recently shared his experience with health care coverage in California. He is in his 40s and lives with his wife and their two children. Bill is the family’s primary income, but like many Californians who work as independent contractors, he does not have employer-sponsored insurance.

What are his family’s medical needs? Bill reports that he’s been lucky to be healthy. His wife has a chronic condition that requires regular medical attention. His kids have the usual coughs and colds and occasional broken arm. “We make sure to get all of our annual physicals and flu shots.”

How is he covered? Bill and his family do not have traditional insurance. He makes too much money to qualify for subsidies through California’s federal marketplace (Covered California), but not enough to afford any of the plans. Therefore, he buys concierge and catastrophic policies. “I want real coverage, but it’s too expensive.” (1)

How much does he spend on health care? Bill spends $350 per month for concierge care with a local primary care physician. He and his family can visit the physician as often as they’d like with no additional out-of-pocket expenses, but not any other provider. “It’s worked well for me, my wife and my kids. Our doctor really knows us.”

What about a catastrophic event? Bill wants to protect his family’s finances if there is a major expense such as a hospitalization. He bought an off-exchange catastrophic plan for additional protection “even though it won’t cover much if I ever have to use it.” (Catastrophic plans on the marketplace are limited to people <30 years old.)

Where do they get prescription drugs? Canada. His wife’s chronic condition requires daily medication, which Bill pays for out of his own pocket. Given the cost of prescriptions in the U.S., he buys it online from Canada. “It’s amazing how cheap drugs are in Canada.”

What about other Californians? Like most states in the U.S., more than 90 percent of Californian have health insurance. Less than half (46%) have employer coverage, 36 percent have Medicaid (25%) and Medicare (11%), and 9 percent have non-group, individual, and other coverage. The remaining eight percent are uninsured. (2)

What else? Bill worries about changes to the Affordable Care Act that might permit insurers to exclude coverage for pre-existing conditions. In addition to his own family’s health issues, he knows that in Southern California (Los Angeles-Long Beach-Anaheim), an estimated 23 percent of people have a pre-existing condition. (3)

Open enrollment for the 2019 plan year begins on November 1. Bill will be exploring his options on Covered California again, including any new options that might provide him and his family with better coverage at an affordable price. In other words, he’s Mastering Health Insurance.

Sources:

(1) https://www.coveredca.com/

(2) Kaiser Family Foundation. 2016 data. Go to: https://www.kff.org/other/state-indicator/

(3) Kaiser Family Foundation. “New Analysis Maps Prevalence of Pre-Existing Conditions by Metro Area”