In late October 2015, former Henrico County resident Daniel Bowling, then 27, was working at a golf shop in Myrtle Beach, South Carolina, when he felt progressively sicker and weaker. He was losing weight. So he went for a blood test.
His doctor told him to get to an emergency room right away. More tests were needed. "My white blood cell and platelet counts were off the chart. My spleen was enlarged," Bowling says. "They thought it was cancer."
An ambulance took him to the Medical University of South Carolina two hours away in Charleston where more advanced care was available.
There, he received the diagnosis: He had leukemia, which is usually deadly.
More jolting news followed: The hospital declined to accept the Blue Cross-Blue Shield of South Carolina insurance plan that he'd purchased on a federal health exchange under the Affordable Care Act, he says, otherwise known as the ACA or Obamacare. The hospital treated him but it was out of his insurer's network, so it wouldn't pay his bills. Bowling later sued the insurance company, which did not respond to queries from Style Weekly.
Bowling played his ace in the hole. He called his mother, Cindi Jones, who was director of the Virginia Department of Medical Assistance Services and an expert on health insurance. Until she retired from state service Jan. 12, she was the leading state official for administering the federal Medicaid program for lower-income Virginians.
Jones drove to Charleston. Doctors said her son wouldn't survive a car ride back to Richmond. After a week in South Carolina, she got him hospitalized at the Virginia Commonwealth University Health System, which offers advanced cancer treatment services led by the Massey Cancer Center.
- Scott Elmquist
- Cindi Jones and her son, Daniel Bowling, fought to get insurance coverage to battle his cancer.
For the next two years, mother and son endured bump after bump with health insurance. While treatment at VCU went well and Bowling successfully underwent a bone marrow transplant in October 2016, constant changes in politics and policies surrounding Obamacare have made their lives a roll of the dice.
The ACA is undergoing regular attack from opponents, such as Republicans in Congress and President Donald Trump, who has vowed to "repeal and replace" but so far has failed to do so.
Since returning home from South Carolina in 2015, Bowling has gone through three different insurers. They include Blue Cross and Blue Shield of South Carolina, which ironically agreed to cover him at VCU for months but not in Charleston because VCU was included in their network. Next came Anthem Blue Cross and Blue Shield, which offered coverage in the Richmond area for decades.
- Scott Elmquist
- President Donald Trump has tried to stymie Obamacare but failed to repeal it.
But last summer, Anthem announced that it was pulling out of its home market and many others, saying it was concerned that rising ACA costs were making other customers overpay for their plans.
Under tremendous political pressure in the fall, Anthem agreed to take back customers in many rural areas, including Goochland County. But Richmond and the counties of Henrico, Hanover and Chesterfield were left out.
The timing was awful for Bowling and his mother. The anticipated recovery time for a bone marrow transplant can be five years while a body gets used to the immune system from the marrow donor. Being close to an advanced cancer center like VCU is essential when simple infections can quickly become deadly.
But when Anthem dumped ACA coverage in much of the greater Richmond area, making VCU out of reach for many, it made the next closest center on VCU's level a two-and-a-half hour drive away at Duke University Health System in Durham, North Carolina. "We actually started planning to move to North Carolina," Jones says.
In yet another bizarre twist in the fall, it appeared that Bowling could continue to be treated at VCU if he moved to Goochland County, a few miles west of his mother's home in Short Pump.
That's because Anthem agreed to take back its coverage in Goochland after being muscled to return to many of the rural areas it tried to dump. "We thought about getting an apartment there," Price says.
- Scott Elmquist
- Protesters support the ACA at Capitol Square at a Save Our Health Care rally on Jan. 15, 2017.
The latest news is that Bowling seems to be OK, insurance-wise, at least for now.
On New Year's Day, he was put on a plan by Cigna, a national insurer that signed on at VCU late in the game in mid-November to replace Anthem.
Bowling says he has no idea if he'll have to go through the wringer once again because his Cigna plan is good for only one year. Insurance, health care companies and others are just starting their planning for setting rates and coverage areas for 2019.
"It shows just how crazy insurance has become," says Jones, who's been on the front lines of a years-long General Assembly fight over expanding Medicaid coverage to nearly 400,000 lower-income Virginians.
She blames "90 percent" of the current chaos on Trump, who's tried ploy after ploy to undermine Obamacare without offering any clear substitute.
Since failing to repeal ACA, Trump has been steadily slicing away at it. As the open enrollment period began in the fall, Trump arranged to have its time cut in half. Then the computer system for signing up was shut down on Sundays "for maintenance."
- Scott Elmquist
- Michael W. Gentry, a Sentara Heathcare executive, talks about a poll showing big support for federal spending on care for the poor.
In September, Trump suddenly ordered the federal Centers for Medicare and Medicaid Services to cut off payments of federal ACA subsidies called cost-sharing reductions, known as CSRs.
These offer qualifying, lower-income people a way to help pay for out-of-pocket expenses for doctors' visits or drugs. They're given a lower out-of-pocket maximum — the total paid for covered services each year. Once that number is reached, the ACA plan covers everything.
The ACA requires — and this seems to be part of Trump's scheme — that insurers provide all of the services called for by the ACA. But it doesn't say the federal government must pay for them. Trump has argued that Congress didn't properly pass CSRs, and a court decision has backed him.
Still, not paying the subsidies for nearly six months puts pressure on legislators to play along with Trump and makes it more difficult for people to get insurance.
Jill A. Hanken, a lawyer with the Virginia Poverty Law Center, says cutting subsidies with no plan to provide other funding takes a cruel toll on lower-income people.
Doug Gray, executive director of the Virginia Association of Health Plans, says Trump's threats were intended "to implode the market" and force legislators to "consider his ideas."
Democratic politicians deplore Trump's tactics.
Virginia Sen. Mark Warner wrote in a statement to Style that Trump's "destabilizing" actions will mean that Virginia families will be "left to pay the price of this sabotage through higher premiums, fewer choices, and less coverage."
U.S. Rep. Donald McEachin, a Democrat who represents the 4th District, says that terminating CSR subsidies and other actions "have driven up costs and reduced choice — not just for individuals who received the payments, but for anyone who buys coverage through an individual marketplace."
Republican U.S. Rep. Dave Brat, a critic of the ACA who represents the 7th District, declines to comment. He's faced public opposition at town meetings for his positions on health care.
But venting about Trump's ploys doesn't address some basic problems that exist with Obamacare.
Since the ACA marketplaces were introduced in 2014, the number of insurers selling on them has steadily declined. At first there was an average of five per state, according to Kaiser Family Foundation data. Now there are three and a half.
Virginia remains covered by six, including Optima, Kaiser, Piedmont, Cigna, CareFirst and Anthem. Aetna and United Healthcare pulled out of the state last year and others have cut back on services.
Driving their decisions to stay or go is simple economics, Gray says. As the ACA took effect, it became clear that the number of ill people had been miscalculated. "In a lot of states, people were sicker than known," he says. "Companies lost money each year and have to make decisions about rates."
"The focus earlier was to try and get enough wealthier people," he says, "but as the losses started to mount, the premiums started to go up. And as the premiums went up, it became less and less attractive to people who were well."
Anthem spokesman Scott Golden writes in an email to Style that the volatility in ACA markets made the company reassess what products it would offer and where.
Anthem constructs products based upon the "broad spreading of risk" and a "known set of conditions," he writes.
"Today," Golden adds, "planning and pricing for ACA-compliant health plans has become increasingly difficult due to a shrinking and deteriorating individual market," along with the uncertainty and changeability of federal rules.
That thinking was the basis of Anthem's decision to announce its departure from Richmond along with more than 60 smaller cities and counties. The uproar was intense.
Price says she recalls former Gov. Terry McAuliffe's angry, behind-the-scenes reaction when it became plain that Anthem's plans meant that more than 60 rural counties and cities could be left with no ACA insurer.
Democratic U.S. Sen. Tim Kaine said "he would not tolerate" such a situation. Anthem soon announced that it was returning to more than 60 markets but not Richmond.
Golden writes to Style that "we remain committed to ensuring that all Virginians have an option for health insurance available to them."
He also notes: "The ACA Marketplace is a small percentage of our business in the Richmond market and across the state. The majority of our business is group health insurance, which is offered by employers to their employees."
Anthem's decision to pull out from Virginia, at least at first, was catnip for state Republican legislators.
Former Speaker of the House William J. Howell, R-Stafford, and Senate Majority Leader Thomas K. Norment Jr., R-James City, have applauded Anthem's decision as clear evidence that the ACA had failed and should be repealed.
"Obamacare is hurting more people than it is helping, forcing Americans to buy insurance that they don't like, they don't need and can't afford," Howell said in a statement Aug. 11.
Anthem's decision regarding the ACA markets didn't end all of its problems. It also announced that it wasn't renewing its contract for 2018 with VCU Health Systems.
That was important because VCU has one of the leading medical centers in the state with a top-level trauma center, an advanced cancer center and a special hospital for children.
The possibility first became known as likely when two VCU specialists were in contact with a national online chat room for medical professionals in the late summer. They came to realize that Anthem really did intend to leave. There had been suggestions about it before.
"I think it was early fall when we learned that there may not be as many plans that we were going to sign up," says Sheryl Garland, VCU Health System's vice president for health policy and community relations. "And that there was concern statewide about what was going on with the marketplace."
Patients didn't know what to think. "There was so much confusion about what was happening," she says.
What was known was that Anthem had announced it was abandoning its ACA plans and that Cigna had applied to be an ACA carrier in central Virginia but not at VCU. If so, that left VCU in the lurch.
A flurry of meetings followed. Involved were VCU, Cigna and HCA Healthcare, a national company that operates several hospitals in the Richmond area, including Johnston-Willis and Chippenham and has ties with Cigna. VCU officials talked with Cigna, saying they had a serious problem, Garland confirms.
Finally, on Nov. 15 — six weeks before the Anthem contract would expire — a deal was announced that Cigna would contract with VCU for insurance.
Cigna media spokeswoman Courtney Nogas says her company was happy for the business "because of our relationship with the customer and our staying power."
For Danny Bowling and his mother, there's some degree of relief — but more work ahead and more uncertainty. Battles over the ACA are far from over.
Because Cigna is the new carrier, Price says, "We need to get Cigna to get authorization for all of his drugs all over again."
- Scott Elmquist
- Then-Lt. Gov. Ralph Northam greets supporters Shreya Dwibedy and Shaila Lothe from Henrico High School last year.
They'll be watching closely while the negotiations for ACA premiums and coverage begin and carry on throughout the spring and into the summer when final deals are cut and the State Corporation Commission makes its decision on rates and other matters. Then, the matters go to Washington for final rulings.
The recent confusion over Obamacare might have an unexpected result. Jones says that the chaos of 2017 will put emphasis on expanding Medicaid to nearly 400,000 lower-income Virginians. Opponents at the General Assembly, mostly Republicans, fought it successfully for four years, saying it was too expensive.
Jones, who used to head state oversight of Medicaid, says that part of the problem was a political battle involving McAuliffe, a Democrat.
Now he's out of office, a physician has taken over as governor, and national media have picked up on expanding Medicaid as a way to solve some of the unresolved messes of Obamacare.
Expanding Medicaid seemed to get a boost Jan. 16, when the Virginia Hospital and Healthcare Association announced the findings of a survey conducted by Public Opinion Strategies, a polling group with ties to the Republican party.
It showed that four of five Virginia voters favor a plan to draw down federal funds to help low-income, uninsured Virginians get health care coverage.
Bowling is now $40,000 in debt and has filed suit against Blue Cross-Blue Shield of South Carolina. John Tiller, the insurer's lawyer, spoke with Style but did not comment. Bowling didn't include the Medical University of South Carolina in the suit. His mother notes that the hospital has deferred seeking payment of the debt until the lawsuit is settled. A representative for the hospital declines to comment.
Otherwise, Bowling is upbeat. He says he's "good to go," although he still has some cancer. "I can call myself in remission," he says. "I'm going to get a job and start my life over." S