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For a West County couple, health insurance couldn't come soon enough

For a West County couple, health insurance couldn't come soon enough

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Tom and LaDonna Appelbaum have a knack for good timing.

The West County couple spent a nerve-wracking four years without health insurance but never had a serious medical issue to worry about.

“That was not a smart thing to do for us to go that many years without health insurance,” LaDonna Appelbaum said. “Fortunately, we were lucky for that long.”

When it came time to sign up for coverage under President Barack Obama’s health overhaul last year, the Appelbaums decided they weren’t going to take any more chances.

They signed up in February for an Anthem Blue Cross Blue Shield in Missouri “silver” plan, which generally covers about 70 percent of health care expenses. They qualified for a subsidy to help reduce the cost of their monthly premium.

And it wasn’t a moment too soon.

In June, Tom Appelbaum, a self-employed attorney, had a boating accident that required surgery on his right hand. And just two months later LaDonna Appelbaum was diagnosed with breast cancer.

The Appelbaums said their insurance saved their lives and their wallet. Without it, they would be hard-pressed to pay their medical bills.

“Their experience just shows how critical it is for people to have health insurance, even if they don’t think they have health problems,” said Jen Bersdale, executive director of Missouri Health Care for All, an advocacy group.

Their journey to health insurance coverage was a trip fraught with anger and frustration. But now the Appelbaums are reaping the benefits, and they couldn’t be more thankful.

“I am so lucky that I have health insurance,” LaDonna Appelbaum said. “I can’t imagine what it would be like without it.”

TROUBLED PREGNANCY

The Appelbaums hadn’t been trying to start a family, but they were thrilled when LaDonna, 47, became pregnant in 2010. Their joy was short-lived.

They quickly found that the insurance plan they purchased on the individual market didn’t cover services for pregnancies.

“It’s almost like a hostile market when it comes to health insurance,” Tom Appelbaum, 49, said. “We learned some really disturbing things with how they handle pregnancies.”

To get a plan to cover pregnancy, the Appelbaums would have had to pay at least an additional $1,000 a month and would have had to wait a year before coverage started.

That’s because pregnancy, in some cases, was viewed as a pre-existing condition by insurance companies in the individual market — allowing them to deny care or raise prices.

“It was really not a good system for women or babies,” Bersdale said.

LaDonna Appelbaum ended up having a miscarriage, but their frustration with the health insurance industry caused them to drop it altogether.

Starting this year, the Affordable Care Act prohibits companies from denying coverage or charging more because of a pre-existing condition. That paved the way for the Appelbaums to get coverage, which started in February, without having to worry about higher rates because of a pregnancy or other medical conditions.

UNHEALTHY START

Tom Appelbaum had been insured for only a few months when he had to have surgery on his right hand. He had a “Jersey Finger” injury in which the tendon in his hand was pulled completely off the bone.

He required weeks of physical therapy. LaDonna Appelbaum estimates the ordeal would have cost $35,000 without insurance.

While her husband was recovering, LaDonna Appelbaum noticed a lump on her breast.

“I thought it was a bug bite,” she said.

In August, she was diagnosed stage IIIA breast cancer. She had a double mastectomy and is now starting chemotherapy and radiation treatments.

Breast cancer doesn’t run in her family so the diagnosis was a shock. But LaDonna Appelbaum is thankful she had the safety net of her insurance plan. She knows the Affordable Care Act was and remains controversial, but to her the politics doesn’t matter.

“I would like to talk to anyone that thinks this is not a good thing,” she said. “I feel like I am a walking billboard for why having health insurance is so important.”

With the second health insurance enrollment period under the law now underway, the Appelbaums are considering their options.

LaDonna Appelbaum said they expect to sign up for the same plan for 2015 coverage because she is nervous about losing her doctors. It’s been everything they’ve needed.

“To say that the exchange was a lifesaver for us would be an understatement,” Tom Appelbaum said.

This report was prepared in collaboration with Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Jordan Shapiro is a reporter for the St. Louis Post-Dispatch.

Related to this story

Even if the Missouri Department of Insurance wants to protect the state's citizens who get insurance under the Affordable Care Act from being gouged by health insurers, it can't.

The Republican-controlled Missouri General Assembly has stripped the regulatory agency of its authority, making Missouri the only state in the country in which health insurers are not required to disclose rates to regulators proposed under the ACA.

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