THIS TIME ON CODE WACK!
Join us on a deep dive into the hidden forces behind soaring out-of-pocket costs, from rising medical costs to pandemic aftershocks and corporate profit pressures. Our guest, health insurance agent Sherry Davis Johnson, shares eye-opening stories from the front lines. We’ll also explore how the Affordable Care Act has saved lives, what protections still matter most, and what it really takes to navigate today’s healthcare maze. This is the second episode in a two part-series.
Sherry Davis Johnson — a former nurse turned long–time insurance agent in Southern California — has seen our challenging healthcare system from every angle, as a nurse and home health provider, insurance agent and patient. Today, she’s here to help us make sense of it all.
Check out the Transcript and Show Notes for more!
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SHOW NOTES
WE DISCUSS
What do you think is driving the increases in people’s out of pocket healthcare costs?
Johnson: “What’s driving the increase is that vendors and providers are raising their prices. MRIs cost more, CAT scans cost more, and ambulances cost more. And that’s driving the cost of healthcare up … we don’t have any controls over that at all.
“We are still probably calculating the sum of exposure from COVID, but I know it took a couple of years before some providers were even able to submit bills to the insurance company. So those are still being calculated and as you know, it was high use and a lot of people didn’t have any coverage.
“And because we had the [COVID] shutdown for so long, a lot of people weren’t working and unemployment was not enough money to pay for [health insurance], which is why the Inflation Reduction Act stepped in to help with bigger subsidies and lower out-of-pocket share of cost.
“And a higher number of people were able to be enrolled in Medi-Cal … Medi-Cal in California, Medicaid in the rest of the country … without having to do anything different ….”
When it comes to the cost of care, it’s not just premiums that are concerning. Can you talk about how the out-of-pocket maximum works?
Johnson: “… if you have a health plan … [with just] one day in the hospital you will reach your out-of-pocket maximum. And most people can’t afford the out-of-pocket maximum.
“The out-of-pocket maximum is the amount of money that you will pay between January 1st and December 31st for your healthcare during the year (besides the monthly premium). So that means every time you go to the doctor, depending on your plan level, you have a copay to go see the doctor, and that money gets added to your out-of-pocket maximum. Not necessarily your deductible, but your out-of-pocket maximum.
“The [annual] out-of-pocket maximum … [applies to care provided] between January 1st and December 31st. So I’ll give you an example of how it works. If you had an accident on December 29th and you got out of the hospital on December 30th, you owe the hospital $9,100.
“If you got out of the hospital on January 3rd, you owe the hospital $18,200.”
Bad as things are today, would you say we are better off than we were, before the Affordable Care Act?
Johnson: “It seems ridiculous now, but it’s so much better. The best thing of all is that you can’t get kicked off your plan because you utilize too much healthcare, and people don’t understand how real that is.
“I remember watching a story on ABC News decades ago, and a little girl with cystic fibrosis was being moved out of the hospital to her home because she ran out of health insurance for her life…
“For her lifetime. There used to be a lifetime cap and an annual cap on your health insurance. Most people don’t know you could not use more than a million dollars in a calendar year or $5 million in your lifetime. The ACA got rid of that.
“… By 2008 I was mortified that more than 70% of the people that called me and wanted health insurance were unable to get insurance because they have preexisting conditions. Preexisting conditions like “Have you taken Claritin in the last six months?”
“We had a telephone book that was about an inch thick .. that had a list of medications in four columns. And if you took any of those medicines, no coverage for you. Automatic denial ..
“It was that terrible. And so for the pre-existing condition clause to be removed was a wonderful thing.
“I don’t know if you’ve ever heard Stevie Wonder’s [Journey Through the] Secret Life of Plants, but it’s the most beautiful opera I’ve ever heard. And I read through the end of the Affordable Care Act and I thought, ‘Wow, this is the most beautiful legislation I have ever read.’
And it was spectacular because it addressed the immediate suffering of people who didn’t have health insurance coverage.”
Helpful Links
Understanding the ACA Subsidy Discussion, Committee for a Responsible Federal Budget
Understanding Out-of-Pocket Expenses: Definition, Types, and Examples, Investopedia
HMO vs. PPO: Which health insurance plan is right for you?, Independence Blue Cross
Fact Check: Have healthcare costs risen faster since the Affordable Care Act was passed?, Econofact
Medical Loss Ratio: The ACA Rule That Accidentally Made Higher Healthcare Costs Profitable, MoneyGeek
The ‘good old days’ before Obamacare, Wendell Potter, Health Insurance.org.
Episode Transcript
Read the full episode transcript.
Guest Biographies: Sherry Davis Johnson
Sherry became a nurse in 1985. She has worked in hospitals, clinics, doctors’ offices, long-term care, and as a travel nurse. Home health was her favorite.
Modern Health provided careful infusions, critical observation, and accurate documentation for special studies programs at UCLA during the early days of the AIDS crisis for Michael Gottlieb, MD, and Ardis Moe, MD. Sherry held many clinical positions within that uniquely talented company of nurses, from a visit nurse, intake and staffing coordinator, insurance case coordinator, sales, and assistant director of nurses. Sherry learned to navigate through the care, treatment, and authorization process. She learned insurance from the provider’s perspective.
In 2003, Sherry began her career as an insurance broker, providing exceptionally well-orchestrated employee benefits packages for companies ranging from 2 to 1,700 employees. She learned insurance from the employer and employee perspectives.
Between April of 2009 and June of 2010, Sherry had five major surgeries, including a 13-hour pancreatic surgery and neurosurgery to remove a golf ball-sized pituitary tumor. She learned insurance from the patient’s perspective.
Sherry Davis Johnson is a property, casualty, accident, health, and life insurance agent, Medicare-certified in the states of California, Colorado, Florida, Georgia, Michigan, Montana, Nevada, Texas, and Washington. Certified through healthcare.gov and state exchanges.
Each of these experiences on her journey has culminated in her ability to give expert advice from the employer, provider, patient, and insurance agent’s perspectives to anyone in need of guidance. Sherry is a nurse masquerading as an insurance agent, and that makes Sherry feel like a superhero.
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