Faces of Health Care Debate Point to New Law’s Complexity

WASHINGTON — They were the human faces of the nation’s wrenching, yearlong health care debate.
Natoma Canfield of Medina, Ohio, sent a letter to President Obama about no longer being able to afford her health coverage, and he read it aloud to a group of insurance executives at the White House. Then Ms. Canfield learned she had leukemia, helping Mr. Obama illustrate the life-and-death stakes of the often mind-numbing policy fight.

Marcelas Owens, an 11-year-old boy from Seattle, whose mother could not get some treatment for lack of insurance and died at age 27 from pulmonary hypertension, met Senator Patty Murray, Democrat of Washington, at a rally and ended up by the president’s side at the bill-signing ceremony. “I don’t want any other kids to go through the pain our family has gone through,” Marcelas said.

And Molly Secours, a filmmaker from Nashville, who battled uterine cancer, nearly lost her home because of medical bills — even though she had health insurance. Told that she would need a radical hysterectomy, chemotherapy and radiation treatment, Ms. Secours said, “I was consumed with the fear that I’ll have to declare bankruptcy.”

But if their stories helped the Democrats pass the health care overhaul, a more complicated question is: What will the health care law do for them?

Revisiting their cases illustrates both the enormous potential benefits of the new law, which seeks to insure some 32 million people, and also how the complexity of the health system will continue to pose a formidable challenge for patients and health care providers in the months and years ahead.

Of the cast of Americans who made appearances in the health care debate, Ms. Canfield, who is undergoing chemotherapy and preparing for a bone marrow transplant at the Cleveland Clinic, may have had the biggest role.

Her story led Mr. Obama to hold a rally in Ohio, not far from her home, which helped secure the vote of Representative Dennis J. Kucinich, a Democrat who had opposed the bill. Then, Ms. Canfield’s congressman, Representative John Boccieri, a freshman Democrat, cited her in announcing that he, too, would support the bill.

As it turns out, Ms. Canfield’s grave illness means that her time as one of the roughly 50 million uninsured Americans was brief. In recent days, she was approved for Social Security disability benefits and Medicaid, the federal-state insurance program for low-income people.

“She is no longer able to work,” said her sister, Connie Anderson. “She has kind of dropped down into a different category.”

Supporters of the legislation say that proves one of their main points — the existing system provides little help until catastrophe strikes and, even then, it entails a maze of bureaucracy.

But for some critics, the Cleveland Clinic’s quick reassurance that Ms. Canfield need not worry about losing her home to medical costs showed that Mr. Obama exaggerated her case. On Fox News, Sean Hannity accused Mr. Obama of lying about Ms. Canfield’s situation.

Ms. Canfield got a break. Her local hospital, Medina General, was taken over last year by the Cleveland Clinic, a prominent hospital system with a sophisticated patient-support structure.

In interviews, Ms. Canfield and her sister credited the hospital with helping secure government aid. Leukemia is on Social Security’s list of “compassionate allowances” for an expedited disability ruling. Were she not disabled, Ms. Canfield could not qualify for Medicaid in Ohio under current rules even though she earned well below the federal poverty limit.

That will change as a result of the new law, which will expand Medicaid in 2014. Between now and then, Ohio residents may benefit from the creation of a high-risk insurance pool, either at the state or national level. While other states already have such programs, Ohio does not.

But while the bill provides $5 billion to create or expand such programs, it is not clear how they will work. Premiums are often expensive, and payment rates for providers have not been set. That makes it impossible for a hospital to know if it would be paid more by a high-risk policy or by the state’s existing Hospital Care Assurance Program, which reimburses for care of the uninsured.

In the current system, Lyman Sornberger, the executive director of patient financial services at the Cleveland Clinic, said that Ms. Canfield had good reason to worry about being forced to sell her home to pay medical bills.

“Facilities or health care systems have an option to decide what their charity care is,” Mr. Sornberger said. “They could put a lien against her home. They could harm her credit. They could ask her to sell all of her assets and sell her home and pay that bill off to that health care system before they agree to give her any charity.”

Even with Medicaid paying the hospital bills, Ms. Canfield’s sister said she was worried about how she would pay her basic expenses, like property taxes and utility bills. Her disability payments do not begin until July, and even then will not cover all her expenses, Ms. Anderson said.

In the case of Marcelas Owens’s mother, Tiffany Owens, it is unclear that the health care legislation would have prevented her from falling into a gap in coverage that prompted her to forgo treatment and may have contributed to her death.

Ms. Owens briefly had private insurance through her restaurant management job. But in October 2006, when she could no longer work because she was sick, she lost both her job and her benefits.

She applied for Medicaid but was rejected because she had earned too much earlier in the year. She was told to reapply in January, but by then she was hospitalized. Six months later, she was dead.

“There was that lapse of time where the sickness was still progressing and there was nothing she could do until she could go back and reapply again,” said Gina Owens, her mother. “It’s just crazy that people fall through the cracks.”

It is not clear if the new health care law will help when a person’s employment, insurance and health status change so rapidly.

Beginning in 2014, low-income Americans who do not qualify for Medicaid could get subsidies to help buy private insurance. But a new system could have pitfalls.

For Marcelas himself, the most immediate benefit of the new law may be a provision barring states from cutting Medicaid rolls. Even when his mother was alive, Marcelas and his two sisters were on Medicaid.

Under the new law, primary care doctors will be paid higher rates to treat Medicaid patients for at least two years. The bill will also provide billions of dollars in additional aid to community health centers, like the Seattle Indian Health Board, where Marcelas gets his pediatric care.

In Nashville, Molly Secours thought she had the system figured out. She had health insurance from Blue Cross, a house and a film company. But after uterine cancer left her with huge bills, she nearly lost her home.

Congress came to the rescue, not with legislation but in the form of Representative Jim Cooper, Democrat of Tennessee, who helped her negotiate a new mortgage. Ms. Secours joined Speaker Nancy Pelosi at a news conference at the Capitol in July.

She is still paying off some bills to Baptist Hospital, but her home is secure. As someone with a pre-existing medical condition, Ms. Secours, under the new law, is assured of being able to find coverage. And as someone who buys her policy on the individual market, she may find better insurance or at least more options.

“People like me who have a major diagnosis aren’t going to get turned down because they had cancer,” she said.

Ms. Secours said she hoped to one day be able to take advantage of tax credits that the new health care law will give to small businesses to help them provide insurance to employees. “A couple of years from now I might be able to hire people and offer them something,” she said.