Fairness of insurance caps is questioned

People in need of organ transplants, or with rare blood diseases, chronic illnesses, or cancers that require expensive therapies tend to be most likely to hit a lifetime cap.

Rick Lofgren, president of the Children's Organ Transplant Association, said, "we're seeing more patients anecdotally that are hitting caps, and we're seeing unfortunately more caps that are being dropped as low as $250,000.

"For most patients, that doesn't get them out of the hospital following a transplant . . . I'm seeing that as a bigger concern."

Beth Darnley, the chief program officer for the Patient Advocate Foundation, a nonprofit that helps 44,000 Americans a year without insurance, said "layers of caps" are causing more problems for patients - caps on the number of visits, the amount spent per incident and per year, as well as lifetime limits. "Now you're subject to four different caps, and that is very prohibitive for patients," she said.

Darnley recognizes the bind that employers are in. If they cover those in greatest need, they risk not insuring other employees. "I can't even make a moral judgment on that," she said.

When Brockington was diagnosed and couldn't work, she lost her job. But her employer, Trans World Entertainment, which owned the Sam Goody store, kept her on insurance for several months.

When it would no longer carry her, she started paying $278 a month under COBRA, a federal law that allows workers to continue their health insurance up to 18 months.

It was after 10 months on COBRA that Brockington got her letter, telling her she had reached the lifetime limit.

Without insurance, she has been scrambling.

Even in remission, she still needs considerable health care. On Tuesday, she had a bone marrow biopsy to confirm she is cancer-free.

This fall she's had two cases of shingles and one of vertigo, in part because her immune system is still weak.

"She's definitely half the person that she was," said Monaco, who's also out of work and getting covered through COBRA. Their Sam Goody store in Deptford closed in January. "She was fun-loving, teasing, outgoing, funny, and it's pretty heartbreaking to see what's happened to her. But she seems to be coming back."

In November 2007, Brockington was approved for Social Security disability, and began receiving $944 a month.

But that disability income is eaten by co-pays, living expenses, car insurance.

She will be eligible for Medicare - but not until next November. When Congress extended Medicare to include the disabled in 1972, it imposed a two-year wait, which still exists today.

Brockington then tried to get Medicaid, medical coverage for the poor. She applied in New Jersey, but because she owns a mobile home in Delaware, and is licensed to drive there, New Jersey told her to apply there, she said.

Delaware officials, she said, told her that with a $944 disability income, she earns too much to qualify for Medicaid. She plans to apply again soon in New Jersey under a program called Ticket to Work. She has been living in Lawnside for years with her mother and sister - commuting to work in Deptford long before she got sick.

She cannot afford to buy private insurance.