The ‘Man in the Middle’ hits a healthcare Catch-22

Å family falls through a gap in Obamacare

Ever since the Great Health Reform Debate, we have kept in touch with Jeremy Devor, an engineering assistant in the farm community of Salem, IL. Devor contacted us back then and wanted to know what the health reform law would do for him. He was struggling to pay for health insurance for his wife and five children, who now range from 18 to 11, and cover the deductible and co-payments his employer-provided coverage required. We talked to him again in August 2011, after his employer left town and he changed jobs.

Following a family like Devor’s is a reportorial technique we recommend to other journalists. It can combine narrative and storytelling with explanations of difficult policy concepts and how they land in the real world. In Devor’s case, our reporting shows how the new health reform law may not do a whole lot for him, and it also demonstrates the gaps in coverage and care that can result with a healthcare system that’s not universal and always excludes those over some threshold for eligibility, which is the case with the Affordable Care Act.

Devor is the Man in the Middle. He lives in the middle of the country, 254 miles south of Chicago, and after a small raise earns roughly the US median income of about $50,000. With overtime, his pay jumps to about $54,000. In May, his wife Bambi found a waitress job that could bring in another $13,000 or $14,000 depending, of course, on tips.

You’d think the Devor family would be ideal candidates for the new state shopping exchanges that the Affordable Care Act establishes, starting in 2014. But they may not be. Devor has Blue Cross Blue Shield coverage from his employer, a small engineering firm. The coverage for him is good; the deductible, copays, and coinsurance are still low by today’s standards. The price is right, too. His share of the premium is only $28 a month. But that’s just for his own coverage.

Here’s the hitch: His employer doesn’t pay for any family coverage, a situation many Americans face. And sandwiching in the extra $706 monthly cost—the price to cover his family— isn’t possible, given his other bills. He is in a class with several million other Americans with employer coverage who may be stuck with insurance they can’t afford, or that is inadequate. Currently, they can drop that coverage, but that leaves them uninsured with few options.

The Affordable Care Act to the rescue? Not necessarily. The law calculates eligibility for subsidized coverage based on what portion of the total premium the employee pays for himself or herself, rather than the total cost to insure the family. Because Devor’s cost—that $28 per month—is less than 9.5 percent of his gross income for health insurance, the law considers that he has affordable coverage, and thus bars him from shopping for a policy in the Illinois Insurance Exchange and receiving Obamacare government subsidies.

Devor says he just can’t afford that $706 per month. The family’s other bills include payments on $3,000 of outstanding payday loans he took out to pay for new tires—and for hospital and doctor bills that insurance didn’t cover, something of a Catch-22.

“Those payday lending places charge 22 percent interest, and I shouldn’t have gotten them,” he said, “but when stuff like this comes up, what do you do?” He said he could cut the $110 for the cable bill, but the kids use the Internet for school. (All of his kids are good students; most get straight A’s. They also read a lot.) He could cut the $130 cellphone bill, but “How would we communicate?” Except for trimming the $1,200 monthly food tab—tricky with five growing kids—there aren’t many places to cut.

Obamacare may not be much help because a Treasury Department ruling on this matter means that his wife and kids cannot shop in the exchanges because their eligibility would be based on what Devor paid for his own coverage. I asked Washington and Lee law professor Timothy Jost about the status of that rule. Jost said the rule that came out in May “left undecided the question of what happens if individual coverage [from an employer] is affordable, but family coverage is not”—the case for the Devor family. Jost said he didn’t expect the dilemma would be resolved until after the election. So Devor and his family are in a bureaucratic no-man’s land.

In the meantime, his wife Bambi and their children had been eligible for Illinois All Kids, a state subsidized program that has been costing him only $40 a month—until the rules changed. In June, the state sent the Devors a letter saying it had run out of money and needed to tighten eligibility. Bambi became uninsured once again.

His children are covered for now under All Kids, Devor says. But All Kids does not seem to be a good solution: “Almost no doctors accept All Kids, and there is usually a one-month wait for any kind of doctor appointments,” Devor said. Meanwhile, two of the children have bad skin infections, which have been diagnosed as MRSA, a drug-resistant staph infection.The one doctor who would treat the kids prescribed a cream, but the rash hasn’t gone away. “Honestly I don’t think the quality of care is very good,” Devor told me. “But he’s the only doctor we can see in Salem. I want to find a dermatologist, but I have to find one who will take us.” That’s not easy in southern Illinois. “We don’t even go to get check-ups anymore,” he said.

Miranda, Devor’s 18-year old, who wants to be an architect, is attending a community college with the help of Pell grants and her dad’s checks for textbooks. She also works part-time at a nursing home. Miranda may also become uninsured at the end of the year, when she will no longer be eligible for All Kids.

Devor had heard that under the Affordable Care Act, children could stay on their parents’ insurance until age 26. The catch: that works only if there is family coverage, and, as we’ve seen, Devor currently can’t afford that. “If she can’t afford a policy in the individual market—and pay for it herself—I don’t see many options for her now,” said Jost. In 2014, Miranda might be eligible for subsidized coverage under the ACA, but only as long as she is not part of her father’s household; that is, as long as he doesn’t claim her as a dependent for tax purposes.

Devor and I talked about her-not-so great options, and the family’s as well. He believes the president let him down. “Obama made all these compromises to the Republicans to vote for his healthcare plan. None of them made compromises. People really want universal healthcare, not what we got—a pretend system that props up the insurance system. I know plenty of people who work hard everyday, come home tired and dirty, love their kids, and are stuck,” he said.

Devor said he had read about Romney’s plan, and doesn’t like it at all. “From what I understand, he wants to give more tax breaks and give many people high-deductible insurance. That’s a terrible idea,” he said. “I make more money than people I know in my own circle of friends. How are they going to afford those deductibles? They can’t.”

So is he voting for Obama? “No,” he said. In Devor’s eyes, “Obama is clearly the better choice of the two.” But: “I can’t say I’m voting for the lesser of two evils. I will vote for a third-party candidate.”

Related stories:

The Man in the Middle

Revisiting the Man in the Middle

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Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR's healthcare desk, which is part of our United States Project on the coverage of politics and policy. She also blogs for Health News Review. Follow her on Twitter @Trudy_Lieberman.