WF man struggles to find coverage to fight cancer

Dec. 02--Mario Esparza, a Wichita Falls resident with advanced stomach cancer, has fallen through the cracks of the American healthcare system meant to protect poor people from dying for lack of insurance.

Before being diagnosed with cancer early this year, Esparza was a healthy 36-year-old with a job at Alcoa Howmet, a metal casting facility in Wichita Falls. He had been employed there for three years, and before that worked for 11 years as a prison guard at the Allred Unit north of the city. He weighed 220 pounds and considered himself to be in terrific shape.

"Oh yeah, I love sports," Esparza said, adding that before he got sick he played on two softball teams and coached one. In high school in California, he played basketball, football and baseball.

But then in March, his stomach started hurting. He began vomiting. Esparza thought he had contracted the flu, but after laboratory tests came back positive for cancer, he was rushed to United Regional Health Care System, where doctors located a malignant tumor. The disease was already in an advanced stage -- Stage 4, meaning it had spread to other parts of his body, making it more difficult to treat.

After several months of chemotherapy and radiation treatments, Esparza is now a shadow of his former self. His cheeks are hollow and his eyes are sunken. He weighs 105 pounds. Most days, it's difficult to muster the energy to walk from his bedroom to the living room.

"My body's taking a beating right now," he said. "It's hard to eat anything these days because I have no taste buds. My hair's thin, my eyebrows and my eyelashes. I haven't shaved in three months."

While working at Howmet, Esparza paid a relatively low monthly cost -- $150 -- for health insurance. But when he got sick, he was unable to continue working, and though he eventually was allowed to continue coverage through the company's insurance provider as part of the Consolidated Omnibus Reconciliation Act, the cost skyrocketed to $620 a month, he said.

That wasn't a cost Esparza could afford, he said.

Esparza, who has two biological children and two stepchildren ages 5 to 11, was approved for $1,600 a month in disability payments but was turned down for Medicaid services, he said. The disability payments made him ineligible to also receive Medicaid support, he was told. To make matters worse, Esparza's fiancee doesn't have time to earn an income between attending Vernon College full time and taking care of him and the children.

"I've paid into it all my life and I can't get no help now. That doesn't make sense to me," Esparza said."I was told that my income was too much. It's bad, man. I don't understand."

Unable to afford the expensive COBRA insurance, Esparza opted to take out a policy with a provider on the public healthcare marketplace created under the Affordable Care Act. The cost of that program was similar to what he paid for insurance before he got sick.

The problem: few hospitals specializing in caring for cancer patients accept insurance plans underwritten as part of the Affordable Care Act, which is sometimes referred to as Obamacare. In fact, most require health care plans classified as a "preferred provider organizations" (PPOs), instead of the Obamacare plans in the Wichita Falls market, which are "health maintenance organizations" (HMOs).

In the Wichita Falls market specifically, no healthcare insurers in the public marketplace offer qualified PPO plans to individuals on the federal health insurance marketplace, though in the past a handful of insurance companies offered those plans here. The impact of insurers dropping qualified individual PPO plans from public marketplaces has been felt statewide; insurers in the Houston area, for instance, last year opted to discontinue their qualified PPO plans and replace them with HMOs, citing program expense.

The move has caused thousands of people diagnosed with cancer to lose access to the MD Anderson Cancer Center in Houston, which accepts only PPO insurance plans. Cancer Centers of America, which has locations in Tulsa, Atlanta and elsewhere, also does not accept HMO plans.

When the Affordable Care Act mandated in 2010 that insurance companies change the way they offer policies, it did not similarly require healthcare providers to make changes to how providers billed patients and their insurers for medical expenses. PPO plans allow healthcare providers more flexibility in billing, but that flexibility can come at the expense of insurers' bottom line.

Some insurance companies' solution to the problem, said Wichita Falls health insurance expert Kelly Fristoe, has been to drop qualified PPO plans from the public healthcare marketplace and replace them with HMOs, which place more stringent rules on reimbursement for expenses.

"It's a very restrictive form of coverage, these HMO plans are. It's not profitable for the cancer centers to be HMO providers because the (insurance) reimbursement will be very low," said Fristoe, a vice president for the National Association of Health Underwriters. To the question of whether poor people die because they can't get access to PPO plans on the public healthcare marketplace, Fristoe said, "This is going to be a difficult thing to measure. You're not going to be able to say, 'This person died because of an HMO.' You can still get coverage, it just may not be the coverage they want. But at Stage 4, where you have to seek out a specialist -- if you don't have access to that specialist, that's a problem."

After Esparza secured an HMO healthcare plan, he was surprised to discover that Texas Oncology-Wichita Falls Cancer Center wouldn't accept his insurance. He decided to undergo treatment anyway -- he had to, he said -- and as of November had racked up a $40,000 bill. Esparza pays about $50 a month, but he said he doubts the balance ever will be paid in full.

"My bills are just outrageous right now," he said. "They're just through the roof."

As of this week, Esparza had discontinued the HMO plan in favor of the COBRA PPO plan offered through his former employer, despite the more than $600 monthly cost. His body can't take any more radiation or chemotherapy; Esparza needs a type of care that isn't delivered locally.

"It's been rough with these insurance companies," he said. "I'm going to have to pay this $620 a month because I know I'm going to die if I don't."

The dimness of Esparza's current situation may be brightening -- his most recent CT scan showed that his tumor has shrunk. He remains hopeful that he persevere through the disease.

Additionally, Fristoe, the insurance underwriter, said that healthcare providers sometimes reimburse health insurance premiums for patients holding COBRA policies. A few of Esparza's former coworkers have pledged to help him pay his monthly premiums.

"I don't think I'm going to die no time soon," Esparza said. "Honestly, I think I"m going to beat it."

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