No Obamacare Plans Cover Treatment at Houston’s Top Cancer Center

KUT 90.5 | By Joy Diaz,

Published November 3, 2015 at 2:27 PM CST

If you're a cancer patient at a cutting edge center like MD Anderson in Houston, you're not going to be covered by ACA insurance in 2016.

The healthcare marketplace is open once again, but if you look closely at the offered insurance plans you might find something lacking: coverage for specialized treatments.

Preferred provider organizations, or PPOs, often cover specialized treatment like care for cancer patients. But the loss of individual-market plan PPOs will affect tens of thousands of people who buy their insurance privately rather than through an employer. Before the Affordable Care Act, it was the way most people who did not have employer insurance got coverage.

Jenny Deam, with the Houston Chronicle, investigates the disappearance of these plans. She says there will no longer be any plans, by any carrier on the federal exchange for the Houston area, that cover treatment at the MD Anderson Cancer Center. How the marketplace got that way, she says, is a little unclear.

"The PPOs had started disappearing a couple of years ago," she says. "The last one in Houston was Blue Cross Blue Shield of Texas and they announced in the summer that they were getting rid of them, that they were no longer sustainable. PPOs with their wider range of network and hospitals... are very expensive."

What insurers have done instead is shift people in the individual market and on the healthcare exchange to HMOs, which are usually less expensive. The downside, Deam says, is that patients with specialized and complex medical needs will have limited coverage.

In her investigation, Deam profiled one cancer patient, Martha Gardenier, who was told by a doctor that she needed to start making end-of-life preparations. She sought a second opinion from MD Anderson, and began to see her situation improve from Stage 3 to Stage 1 cancer. This experience showed Gardenier that not all doctors who treat cancer are created equal – that she was getting better care at MD Anderson.

Now, it's as if that carpet is being pulled out from under her. Gardenier will no longer will have a PPO that will cover the costs as it once did. She's going to have to pay out-of-pocket for care that could reach $10,000 a month.

"Since that article appeared, I've had just dozen of emails, many from other patients who tell the same story," Deam says. "They specifically got an insurance plan that covered MD Anderson.... [Gardenier is] a pretty stark example of somebody who had been pretty much told 'There's nothing more we can do for you,' and she entered a clinical trial, highly experimental, at MD Anderson. And it worked. People like that don't want to hear that cancer treatment is interchangeable."

Listen to the full interview in the audio player above.