Obamacare ‘coverage gap’ excludes 123,000 South Carolinians from health insurance, including Jim Connor

Radiation therapists Jacqueline Poe and Jim DeSautels mark out points to line up for radiation treatment for Jim Connor at Bon Secours St. Francis Hospital. Connor has lost nearly 100 pounds since last year when he began having difficulty keeping food down due to a cancer tumor in his esophagus.

Jim Connor earned between $50 and $75 a week delivering pizzas in Summerville until a cancer diagnosis sidelined him late last year.

The problem is — one of many problems, in fact — Connor has no health insurance.

He can’t get a federal discount to purchase an Obamacare policy. He’s 12 years too young for Medicare. His employer doesn’t offer any coverage.

On Dec. 14, when Connor tried to apply for the low-income Medicaid program at the Dorchester County office, an employee told him he wouldn’t qualify for a policy because he wasn’t disabled or blind.

A spokeswoman for the state Medicaid agency said federal and state requirements prohibit her from discussing the alleged conversation, but as Connor recounts it, the Medicaid employee suggested that he drink some green tea and research his cancer diagnosis online.

“I was in tears,” he said. “She has no clue.”

In her Republican address to the nation earlier this month, Gov. Nikki Haley called President Barack Obama’s signature health care law a disaster. She said it’s a “health care plan that has made insurance less affordable and doctors less available.”

That’s not the case for millions of Americans. In South Carolina alone, more than 211,000 men and women have purchased insurance policies through HealthCare.gov since November. The vast majority of them qualify for a substantial federal discount to lower the cost they pay for health coverage.

The Affordable Care Act was designed, in part, to help poor and sick patients pay for health coverage, but Haley’s critique of the health care law isn’t completely off-base. Obamacare isn’t working for everyone, including Jim Connor.

He’s one of an estimated 123,000 South Carolinians who continue to fall through the cracks of the health care system.

While the health care law’s advocates blame Haley and her Republican colleagues for this “coverage gap,” Connor is more concerned about getting the cancer treatment he needs to survive.

Only hospital charity can save him now.

More than a year ago, Connor started losing weight. That was the first sign something was wrong.

In July, when he hit 190 pounds — down from his normal 220 pounds — he decided he should see a doctor. He’d put off scheduling an earlier appointment because he wasn’t insured and couldn’t afford to pay cash for an office visit.

“They wanted like $400 or $500 bucks, and I didn’t have that kind of money,” he said.

Connor finally called the Fetter Health Care Network, which accepts low-income, uninsured patients, but found out he wouldn’t be seen at the Summerville clinic until October. So he waited and he kept losing weight.

The Fetter physician ultimately prescribed Connor some medicine to control his chronic vomiting. The clinic also referred him to a local gastroenterologist. Connor waited another two months for that appointment.

“I was down to 130-something (pounds),” he said.

In December, an endoscopy and follow-up biopsy revealed that Connor had esophageal cancer.

He remembers the oncologist told him, “If you don’t get your chemo and radiation, you’re going to die.”

If Landmark Pizza offered its employees health insurance, or if the Affordable Care Act had been left untouched by the U.S. Supreme Court, or if South Carolina leaders had expanded Medicaid eligibility, or if the 2010 federal law had been written differently to begin with, Connor might not have cancer today.

In other words, if any one of those things had happened, it’s likely that Connor would have had health insurance when he needed it. He could have seen a doctor when he first suspected he was sick. Maybe his physicians could have caught the cancer during an earlier stage.

This is speculative. Even now, Connor can’t predict the outcome of his case. His doctors have not yet offered a prognosis.

“It’s too early to tell,” he said.

Connor’s boss, Bill Olson, owns Landmark Pizza in Summerville. Olson said he noticed Connor’s weight loss about a year ago.

“He was telling me that he was having a hard time keeping food down,” Olson said. “Everyone was saying, ‘You need to go check that out.’ ”

Connor tried to buy an Obamacare policy on HealthCare.gov, but he couldn’t afford any of the plans.

“It was going to be like $400-something-dollars a month,” he said. “They said, ‘Oh, you’ll get a subsidy.’ Nothing for me, though.”

Unfortunately for Connor, that’s how the health care law works. The precise language of the Affordable Care Act only provides subsidies to patients whose income falls between 100 percent and 400 percent of the federal poverty level.

That means a single man, like Connor, could earn between $11,770 and $47,080 a year and qualify for a tax credit to buy health insurance through the federal marketplace.

But the 53-year-old earns far less than $11,770 a year. Because his income falls outside that specific range, he is technically too poor to qualify for the financial aid.

The Affordable Care Act’s architects intentionally wrote the law this way, although, in retrospect, the language has become problematic. They agreed that the very poorest patients shouldn’t have to pay anything for health insurance. They wouldn’t need a subsidy. Instead, they would qualify for Medicaid.

In many states, that’s exactly how the law works.

But a 2012 U.S. Supreme Court decision rendered “Medicaid expansion” an optional provision of the Affordable Care Act. South Carolina Republicans have opted out.

Haley contends that this state can’t afford for the program to grow any larger — even if the federal government pays for South Carolina to expand eligibility.

More than 1 million South Carolinians, mostly children, are already enrolled in Medicaid.

Meanwhile, according to the nonprofit Kaiser Family Foundation, 15 other states aren’t adopting Medicaid expansion, either. Three states are still discussing the issue.

For now, eligibility rules in South Carolina remain fairly strict. With few exceptions, adults who aren’t raising dependent children don’t qualify for Medicaid coverage in South Carolina.

Connor, whose only son is 28, learned that the hard way.

“I’ve been independent all my life,” he said. “I’ve always tried to take care of myself, and I don’t like to be a burden or get a hand-out from anybody, you know? I’ve always been a hard worker. I never planned on something like this to happen.”

South Carolina hospitals also disagree with Haley’s hard line on Medicaid expansion.

“We’ve been advocating for the Medicaid expansion for years now and hope that it will still be a possibility and a reality someday,” said Mark Dickson, the vice president for mission at Roper St. Francis. “It’s really just a simple matter of logic.”

In theory, Medicaid expansion would reduce the amount of charity care that hospitals now provide for their indigent patients. The government reimburses hospitals for some of this uncompensated care, but not all of it.

In 2014, Roper St. Francis estimates it provided $48 million worth of charity care to the community. Medical University Hospital reports that unpaid patient debt and patient financial assistance cost the hospital $80 million that year.

The only reason Connor has reason to hope that his cancer will be cured is because of hospital charity. He qualified for free treatment through a program called Access Health.

“We’ve helped over 3,000 patients over the last year,” said Renee Linyard, program director for the Access Health Tri-County Network. Six of those patients, like Connor, have been diagnosed with cancer.

Access Health screens uninsured patients in the Lowcountry who can’t afford to pay for health care services. The program connects them to doctors and hospitals in the community to provide the care free of charge.

In Connor’s case, Roper St. Francis will cover the cost of his cancer treatment.

Scott Broome, the hospital system’s director of cancer services, estimates Connor’s bill alone will exceed “tens of thousands of dollars.”

That’s probably a conservative estimate.

On Friday, Connor had already spent one week in Bon Secours St. Francis Hospital in West Ashley, hooked up to a feeding tube. His physicians need to figure out why his stomach keeps filling up with fluid. Until then, they can’t treat the cancer with chemotherapy and radiation.

“They’re just the most wonderful people in the world, the nurses and the doctors and the staff here,” Connor said. “They’re really just good people.”

When the Medicaid employee told Connor in December that he wouldn’t qualify for coverage, he applied for the program anyway and returned his paperwork to the office.

Apparently, they never processed it.

In early January, Connor received a phone call from a stranger named Gale Deckard.

Deckard, who also lives in Summerville, explained that she had tried filling out an application of her own, but an employee at the Medicaid office had inadvertently given her the paperwork that Connor had already completed. It included his employment history, financial records, social security card and contact information.

“When I saw the paperwork, and saw Landmark Pizza, I thought, ‘I bet we know him,’ ” Deckard said. “He delivered pizzas to us for quite a few years.”

Deckard wanted to let Connor know that the Medicaid office had violated his privacy.

“I was just so grateful for what she did,” Connor said.

Colleen Mullis, a spokeswoman for the state Medicaid agency, did not indicate if the department had been made aware of this privacy breach.

The Health Insurance Portability and Accountability Act prohibits state agencies, hospitals, health insurance companies and health care providers from disclosing a patient’s personal information. All agency employees are trained to understand the patient privacy law, Mullis said.

The S.C. Department of Health and Human Services, which administers Medicaid in this state, processed two privacy complaints filed by beneficiaries or applicants in 2015, Mullis said.

When Connor found out his own privacy had been breached, he said he was frustrated. But he’s not mad — not about any of it, he said.

These days, he’s leaning on his faith and has been encouraging friends with acid reflux to see a doctor. He believes his own acid reflux caused the esophageal cancer.

“I have strong faith in God. ... Things happen for a reason. We just don’t know what the reason is,” he said. “If this has happened so I can help somebody, that’s good enough reason for me.”

Reach Lauren Sausser at 843-937-5598.