41-Year-Old Father: ‘Obamacare Won’t Pay For My Back Surgery, But It Will Pay For Opioids’

41-Year-Old Father: ‘Obamacare Won’t Pay For My Back Surgery, But It Will Pay For Opioids’

The story of one North Carolina man’s ordeal with Obamacare shows how the federal health care law hurts average American families by denying care.
John Daniel Davidson
By

Most days, Joe Cato is confined to sitting in a chair or lying in bed, heavily medicated or asleep, debilitated by back pain that’s left the 41-year-old husband and father of four unable to work, attend seminary, or run his construction business. He has degenerative arthritis in his lower back and pelvis, a condition brought on after years of working on construction sites as a stonemason and hauling music gear as a worship leader in his church. Even riding in a car is painful, which he must do to get to his health-care provider 30 miles from his home in Waxhaw, North Carolina.

Joe is one of the many victims of Obamacare. His doctors say he needs surgery to repair the nerve damage in his lower back and pelvis, but his insurance company, Blue Cross Blue Shield, won’t cover it. In most of North Carolina, including Union County where Joe and his family live, Blue Cross is the only health insurer still offering coverage on the exchanges established by Obamacare. The only treatment Blue Cross will cover for Joe is pain medication—a battery of prescription drugs he must take daily, including what he calls “comatose-inducing” muscle-relaxers and opioids.

“When people call it being between a rock and a hard place I call it choosing between a firing squad and burning at the stake,” Joe says. If he doesn’t take the drugs, he’ll end up in the emergency room because of the pain. If he does take them, he’s useless as a functioning member of society. “I don’t want to pick either.”

He shouldn’t have to, but the collapse of Obamacare has left him with few choices. As the debate over health care reform rages in Washington DC, millions of American families who purchase health insurance on the individual market are struggling to get the care they need. Joe’s case is just one example of how federal health care policy has crippled the individual insurance market, limiting access to care and leaving families with no good options

How Obamacare Left Joe Cato With No Options

Last summer, when his chronic back pain became unmanageable, Joe was insured by Aetna, which worked with him to diagnose the problem. Aetna paid for CT scans, an MRI, nine spinal injections, visits to the emergency room, physical therapy, chiropractic care, and massage specialists. But last July Joe received a letter from Aetna saying it would be exiting the individual market at the end of the year. Given the company’s financial losses, there was no way for them to stay in the exchange.

Joe and his wife, Becky, tried to expedite the tests and treatments for his back, hoping to get a surgery scheduled before the end of the year. He needs a minimally invasive procedure called radiofrequency ablation, which helps ease pain caused by the degeneration of joints from degenerative arthritis. The surgery involves burning the nerve out of the hip joint, easing inflammation and allowing it to move without causing pain. But it took too long to properly diagnose the problem and schedule surgery before the family’s coverage with Aetna ended.

When Joe went to buy new coverage in January, there was only one option on the exchange: Blue Cross. The company was offering a plan called “Blue Value,” created specifically for exchange customers. The plan is designed to provide general primary care, and little else. The idea is to prevent people from going to the ER for things like the flu but it does little for patients with more serious health concerns.

Under his new plan, Joe lost access to all of his regular doctors, including the specialists he had been working with to diagnose and treat his back pain, as well as the Carolina Medical Center (CMC), the major health-care system in Charlotte that runs 15 hospitals and nearly all the outpatient surgery centers in the area. CMC is the must-have provider network for all of North Carolina south of Raleigh, but his “Blue Value” plan didn’t include it.

What’s more, the new plan denies all radiofrequency ablation procedures, no matter what. Blue Cross deems the surgery “experimental,” even though it’s been around for a decade and Aetna was going to cover the procedure before it dropped out of the market. “The idea that it’s experimental is bogus, that’s not why Blue Cross is denying it,” Joe says. “It’s a business decision for them, plain and simple.”

Now, Joe’s only in-network provider is Novant Health, which stipulates that new enrollees can only see a Novant provider that’s accepting new patients. The closest provider that would accept Joe is 30 miles away. Joe says the Novant facility he goes to is “definitely lower quality” than the CMC clinics and hospitals he had access to under his Aetna plan. “It looks like Fallujah.”

Ironically, Joe and his wife pay more for their Blue Cross plan ($120 per month) than they did for their Aetna plan ($36 per month).

Millions Are Bearing The Brunt Of Obamacare

Joe’s story illustrates in a microcosm what’s been happening all over the country. Obamacare sought to transform the individual health insurance market by making two major changes: 1) forcing everyone to purchase coverage—the individual mandate provision—and 2) forcing insurance companies to cover everyone, even those with preexisting conditions. The idea was that the young and healthy would sign up, and their premiums would pay for the cost of older and sicker people, whose premiums wouldn’t actually cover the cost of their care.

It hasn’t worked out that way. Young people didn’t sign up for coverage on the exchanges in sufficient numbers, opting instead to pay the penalty. Insurers were forced either to raise premiums, which have skyrocketed in recent years, or simply exit the market in the face of huge financial losses.

This year, insurers fleeing the market left 21 percent of all Obamacare exchange customers with only one insurer in their area—including Joe Cato in North Carolina. Next year it might be even worse, with as many as 1,200 counties projected to have only one insurer and 47 counties with no Obamacare insurers at all.

That matters because of people like Joe, who are left with no choices and inferior coverage that won’t pay for necessary procedures—but will pay for opioids. That’s especially callous, given the ongoing opioid crisis. In North Carolina, a surge in drug addiction combined with inadequate resources has forced opioid addicts to seek ineffective care hospital emergency rooms, where they are “boarded” for a few days then released.

Obamacare’s destruction of the individual insurance market has inflicted real suffering on families like the Catos. Joe had to drop out of seminary this year, unable to continue his studies at Charlotte Christian College and Theological Seminary. He’s also increasingly unable to run his construction business. And although the powerful drugs he’s taking ease pain, he’s still destroying his back. Every time he walks, he exacerbates the underlying medical condition. The longer he waits to get surgery, the worse it gets. Surgery would cost him about $20,000 out of pocket, which he doesn’t have. Like many people in the era of Obamacare, he’s relying on a crowdfunding campaign set up by a friend to gather funds for the surgery.

Maybe Senate Republicans will find a way to pass some form of Obamacare repeal. Maybe they’ll try to salvage the collapsing exchanges. Maybe they’ll do nothing, and try to blame it all on Democrats. Meanwhile, Joe Cato and millions of Americans like him must bear the brunt of the failure of our political class.

“We wake up to this reality every day,” Joe says. “Once it hits home, you see the giant debacle that is the Affordable Care Act, and you realize that you hate it. Not because some pundit on TV says it’s bad, but because it’s hurting you and your family.”

John is a senior correspondent for The Federalist. Follow him on Twitter.
Photo Photo courtesy of the Cato family.

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