• Health insurance rate hikes: Costs, causes and effects

• Employers, individuals face tough choices on health coverage

CLEAR SPRING — His wife newly diagnosed with a crippling disease, Jeff Pine was dealing with back pain so severe he had to quit his longtime career as a bricklayer.

And now he was facing another crisis — health care costs.

The Pines needed health insurance they couldn’t afford, yet couldn’t afford to go without.

“It just gets to be a nightmare,” said Pine, 40. “Thankfully, we had some friends, neighbors and church members that set up a fund and helped us. We’re kind of lucky there, blessed that we’re around pretty good Christian people.”

The Pines are not unlike millions of others challenged with finding health care coverage as the nation’s economy has forced many out of work and now limits new job opportunities.

Handling pain

Jeff Pine, who grew up in the rural Blairs Valley area that still is his home, became a bricklayer after graduating from Clear Spring High School in 1987.

He was on a job site in 1999 when he bent to pick up a covered 5-gallon bucket he thought was nearly empty.

It wasn’t.

Others had replaced the bucket with a full one, Pine said, and when he grabbed it, the unexpected strain triggered sharp pain across his back.

In time, a specialist found serious spinal problems and said surgery might be necessary.

After marrying Stephanie in 2001, Pine ignored the pain and kept working.

“I kept on, taking pain pills, and I was probably doing more damage,” he said.

The following year, their daughter, Jordan, was born.

Amid the joy soon came a new crisis.

“I never lost swelling in my feet, my hands, from my pregnancy,” said Stephanie, 38. “I was just extremely tired. A couple of months into having my daughter, I was put in the hospital. I was severely anemic. I had to get a transfusion.”

The condition, which has no known cause and is very hard to diagnose, was diagnosed by her family doctor, Jill Ciccarelli of Williamsport.

“She had these sausage-like, thick fingers and I had only seen it in a textbook and I said, ‘Oh, that looks like something I have only seen in my training,’” Ciccarelli said.

She determined Stephanie has scleroderma, a chronic disease that hardens body tissues. The disease, which affects about 300,000 Americans, has no known cure.

The symptoms “vary greatly from individual to individual, and the effects of scleroderma can range from very mild to life-threatening,” according to the Scleroderma Foundation, the leading nonprofit supporter of scleroderma research in the United States.

“The seriousness will depend on what parts of the body are affected and the extent to which they are affected,” the foundation says on its Web site.

For Stephanie Pine, the disease has caused her stomach to thicken so much that she bleeds internally, Ciccarelli said.

“She can become anemic. She has to have blood transfusions or (the gastroenterologist) has to close off the vessels to stop the bleeding,” Ciccarelli said.

She said Stephanie comes to her office for regular monitoring, and frequently goes to The Johns Hopkins and the University of Maryland hospitals in Baltimore for more specialized care.

Looking for insurance

The company for whom Jeff Pine worked paid him up to $17.50 per hour and its health insurance was covering most of the family’s medical bills, so he was reluctant to leave.

By 2003, however, a doctor with Maryland’s workers’ compensation program, which helps people who have been injured on the job, insisted that Pine quit the company and be trained for a different job.

He resigned that summer.

The workers’ comp program would pay doctors to treat his back, provide tuition for him to attend classes in computer-aided design drafting and give him $362 a week to support his family.

But his family — particularly Stephanie — needed medical insurance, too.

Jeff said he knew he could continue her coverage from the company’s insurer through a federal plan called COBRA. He said he was told Stephanie couldn’t stay on the plan by herself, that he had to remain on it, too.

That meant the family not only would have to pay $480 per month for insurance for her, but $480 more — a total of $960 per month — for his coverage, as well.

That was “outrageous,” Pine said. “It wouldn’t have left us nothing to live on.”

So with federal law giving him 60 days to decide whether to take the COBRA plan, Pine began asking other insurance companies for quotes to cover the whole family.

That’s when he ran into the words “pre-existing condition.”

“They said they could take me and Jordan, but not Stephanie,” he said. “They wouldn’t cover Stephanie with scleroderma, and that was the main reason I needed the insurance. She was getting a blood transfusion at least every month. Plus, all the tests. They had to check for kidney damage, lung damage.”

He was about to give up trying when he learned he had been given bad advice about the insurance.

An insurance agent who specialized in COBRA plans told him, “it wasn’t correct that Stephanie couldn’t stay in the (masonry company’s) plan by herself,” Pine recalled. “She could be on it by herself. We didn’t need to pay double for me and her to be on it.”

“And Jordan and I could get separate insurance” at a lower cost, he said.

The rules are “really confusing,” he said.

“Since COBRA is through a (workplace) group plan, a group plan can’t deny coverage on a pre-existing condition provided she’s never had an insurance lapse,” Pine said. “And she’d never had a lapse.

“But now, a plan we would go out and look for on our own, they can and they do — they can deny on pre-existing conditions.”

The Pines were able to continue Stephanie’s coverage via COBRA for $480 per month. Jeff bought private coverage for himself and their daughter for $250 per month.

His $362 weekly pay from workers’ comp wasn’t enough to pay all of the bills. To make it through, the family spent all of the $13,000 it had been saving for a new house.

Weathering tough times

Ask the family how they made it through those early days.

“Well, family and church,” Jeff replied.

“Leftovers,” Stephanie added, laughing.

And, from friends, a “lot of Sunday meals,” she said, laughing again. “‘C’mon over!’”

“Lot of deer meat, too,” she said.

The family lives in a mobile home on 1,200 acres of field and forest owned by the Washington County Sportsmen’s Club near Clear Spring.

Their rent for living there is “another reason we’re so lucky,” Jeff said. “Very cheap rent. They’ve been pretty decent people.”

Stephanie was raised on the land and, like her parents before her, is a caretaker of the club grounds and lodge.

Jeff grew up one road over, on the other side of a wooded hill that bounds the club property. The two met in junior high school and a few years later, became “kind of like high school sweethearts,” Stephanie said.

Right out of high school, Jeff took a job as a bricklayer. And Stephanie got a job at a mattress factory, where she worked for 10 years.

Back then, she said, “I was perfectly healthy and now, if I fall, I can’t get up. I have to crawl and prop myself up.

“I can’t make a full fist. If you shake my hands, my hands are hard. I can’t flatten my hands out.

“Along with the disease, I have high blood pressure, and I take Nexium twice a day. It helps with the acid reflux. But other than that, a lot more people have worse. At least I don’t have lung or kidney involvement.”

Looking up

Nearly two years after he’d left the masonry company, Pine earned a certificate in drafting from Hagerstown Community College.

Within two months, he was working in CAD — computer-aided design — drawing for an engineering firm in Martinsburg, W.Va. The pay was fair, but more to the point, the family was together on an employer’s health plan.

Jeff said he knew that once he was hired, the company’s health insurance plan couldn’t refuse Stephanie.

“She’d never had a lapse in coverage, so I knew that when I went to work again, that they wouldn’t be able to refuse. I just had to prove that, yes, she did have insurance.”

Around the time Jeff was hired by the engineering company, Stephanie was approved for Medicare health care benefits.

The company’s plan became her primary insurer and Medicare the secondary. Jeff still was getting workers’ comp coverage for his back treatment, and his new employer’s plan was providing general health coverage for him and Jordan.

This company’s health plan was more expensive than the no-deductible plan at the masonry company, he said. The insurance at the engineering firm set deductibles of $1,500 for an individual and $3,000 for a family, he said.

In addition, he said, while his old plan paid all of any claim, his new one paid just 80 percent of most bills. Fortunately, Medicare usually paid the other 20 percent for Stephanie.

But on the lower pay Pine was getting as a draftsman, the expenses overall were much harder to afford.

Between paying the deductible and having to pay 20 percent of his or Jordan’s doctor bills, “we started thinking, ‘Should we have health insurance?’

“But we had to keep it just for fear that something bad would happen, especially because Stephanie was high risk for kidney dialysis and things like that. So I had to keep paying.”

COBRA cost

Fast forward to this past May.

With work slowing due to the recession, Pine said, the engineering company announced it was closing its Martinsburg office and moving back to other offices in the region.

He was out of a job again.

This time, the insurance quote to keep Stephanie, their daughter and him on the company’s plan through COBRA was $1,030 per month.

That was 75 percent to 80 percent of what Pine was to earn in unemployment benefits. Even though Stephanie now was getting $980 per month in disability from Social Security, the couple decided the expense was too much.

They dropped Stephanie and Jordan from COBRA coverage, leaving Jordan with no coverage and Stephanie only with Medicare.

Jeff decided to pay $336 per month to keep himself on COBRA because now he also has a pre-existing condition.

“No, not my back,” he said. Workers’ comp continues to pay for those treatments, he said.

The new problem is “a knot or cyst on my pancreas” that a specialist found while Pine was employed at the engineering company, he said.

In the meantime, he qualified for a federal Pell grant so he could return to HCC to earn a degree in mechanical engineering. He’s about halfway toward that degree now and hopes to finish it before his current jobless benefits run out next summer.

Until recently, he was paying the full premium for his COBRA insurance.

On Sept. 19, he got word that he’s been approved for the insurance subsidy President Obama signed into law in February for those who lost their jobs because of the economy.

As it is doing for many others, the government now will pay 65 percent of the cost of Jeff’s insurance.

A matter of trust

The Pines are grateful.

But even knowing they would benefit from a national health care plan, they don’t like it.

“Right now, we would benefit, but I’m not looking at that right now,” Jeff Pine said. “I’m looking at the future of the country. I’m not looking at personal issues. ... I think it would be a bad direction. I think it would give government too much influence and control over people.

“I’m looking at, like, down the road at my daughter, the debt cost of all that. ... I don’t trust Obama’s plan staying that way long-term. Once the government got control of health care, then they would be able to regulate what it covered, what doctors could do.”

“I don’t trust it,” Stephanie said. “I don’t trust the government. I’m scared to death of this health care proposal.”

What the insurance actually will cover is too important to them now to risk, she said.

“I have to have stuff done every year,” she said. “I need that option whenever I need it because I bleed internally. I’ve been put in the hospital sometimes with my blood level at 4. That’s serious. It’s almost where your organs can shut down. I need the coverage to be there.”

Rather than a government-run health care program, Jeff said, the government should regulate private insurers more effectively.

“Insurance companies send you a form, ‘It will cover,’ and then, they send you a letter, 10 pages, ‘It won’t,’ he said. “If something’s not done right, if a form’s not filled out right, they find every way possible to kick it out.

“People’s going through enough. They pay the premiums. Just pay the bill.”

Insurance information resources

The following are phone numbers for those seeking information about insurance:

• To find out which local Department of Social Services office to go to, call the Maryland Department of Human Resources at 1-800-332-6347. If you have a problem with a caseworker or supervisor, call the same toll-free number.

• If you have a question about the Medical Assistance Eligibility Policy, call the Department of Health and Mental Hygiene at 410-767-1463 or 1-800-492-5231, ext. 1463.

• If you have questions about services covered by Maryland Medicaid or other Medicaid questions, call 410-767-5800 or 1-800-492-5231.

• To contact the Maryland AIDS Insurance Assistance Program, call 410-767-1780.

• To contact the Maryland Department of Aging, call 410-767-1102, 1-800-243-3425 or 1-800-AGE-DIAL.

Next in the series

Maryland is known across the country for its efforts to control health care costs through the state Health Services Cost Review Commission and through the Maryland Health Insurance Plan.