Critical care

Health care coverage is a considerable concern these days—especially if you’re self-employed. Farming remains one of the nation’s most dangerous occupations, and finding the right coverage can be critical. This tale of two farmers gives different perspectives on how they handle health insurance.

When row-crop farmer Kyle Marcum of Centralia, Mo., learned his family’s annual health premium would reach $15,000 for 2017, he dropped coverage for himself, his wife, Tina, and their daughter Megan, 15.

“I’m not working my tail to the bone to make money for doctors and insurance companies,” Marcum said. “We just hope and pray nothing major happens with our health.”

Marcum is not alone. Of 330 million Americans, approximately 28 million remained uninsured in 2016, according to the U.S. Centers for Disease Control and Prevention. That compares to about 48 million who were uninsured when the Affordable Care Act (ACA), also called Obamacare, was first adopted in 2010. Initially, individuals were required to have insurance or pay a penalty, but that mandate will be repealed in 2019. The scrapping of the requirement was part of a new tax law President Trump signed last December.

Fellow Centralia farmer Randy Ridgway, on the other hand, unfortunately knows firsthand the value of having health insurance. His wife, Angie, died in 2014 after a battle with breast cancer. She had health coverage through her job as a school teacher.

“My wife’s experience showed me it’s important to have health insurance,” Ridgway said. “If we didn’t have Angie’s insurance, it would have broke us. She fought cancer for nine years, and the medical bills would have totaled $3 to $4 million without insurance.”

Ridgway, a full-time farmer, was never on his wife’s plan—he purchased his insurance separately. At first, the ACA lowered his insurance costs compared to his previous plan but kept increasing in price until it became unaffordable. When his annual policy skyrocketed to $18,000 a few years ago, he sought alternatives. He now has a private short-term plan that lowers his family’s premium to $4,428. The plan covers Ridgway and his 23-year-old son, Grant, who farms with him.

“I’m now paying $369 per month for both of us,” Ridgway said. “It’s affordable.”

The ACA remains controversial, and it continues to shape insurance markets. Here’s how it works. You can go through a broker or obtain ACA coverage online at marketplace.gov. The federal government doesn’t provide the insurance—private insurance companies such as Blue Cross Blue Shield offer the coverage. The government makes the platform and the rules that insurers must follow.

Depending on income, you may be eligible for federal subsidies or tax credits that lower costs.

“Farmers are often described as being land rich but cash poor,” said Shoshanah Inwood, a rural sociologist with Ohio State University who conducted a 2017 study of farmers and health insurance. “The ACA benefited some farmers because subsidies were based on income rather than assets like land. A lot of farmers got health insurance for the first time through the ACA.”

However, commercial farmers often generate too much income to qualify for subsidies, and without them, the insurance can be expensive. Also, the ACA requires you to predict next year’s income to determine your eligibility for a subsidy, and it’s difficult to forecast income that varies with weather and commodity prices.

“2018 might have been a good year to sign up,” Marcum said. “We’re in a disaster area due to a drought. We were already feeding hay to our cattle in August, when our pasture dried up. Our corn yield will probably drop in half over last year. And tariff threats have lowered the price of soybean futures by $2 a bushel.”  

Another problem farmers find with the ACA Marketplace is that often only one insurance provider offers coverage in rural counties. That includes Audrain County, where Marcum and Ridgway live. Long distances to health care providers can present further problems for rural residents, and doctors and hospitals are becoming more selective about plans they’ll accept.

That’s why many people, including farmers, are seeking private insurance coverage outside the ACA Marketplace. However, it’s often difficult to obtain coverage without belonging to a group. Most farmers are self-employed and don’t qualify for group coverage offered by employers.

Ridgway purchased his short-term health plan from Stan Cuba of Cuba Insurance Agency in Liberty, Mo. Cuba specializes in insurance for rural people in six states, including about 600 farmers.

“There’s a huge market for short-term health coverage in Nebraska, Iowa and Missouri,” Cuba said. “This is a great option for people who don’t qualify for ACA subsidies and are in good health.”

As Cuba explains, a federal law passed during the Obama administration allows for short-term health insurance lasting 90 days. Missouri now allows short-term insurance to renew automatically for a year. Cuba said that the Trump administration is working toward allowing coverage to extend up to a year as in Missouri. However, after the year is up, policy-holders must answer questions about their health, and if they report a problem, the company may refuse coverage.

Ridgway’s National General Accident Health policy comes with an annual deductible of $5,000, which means generally, after that level is met, insurance covers some remaining expenses.   

Not everyone loves short-term plans. Sidney Watson, a St. Louis University law professor and health care expert, expresses caution.

“I worry that we’ll see a return to what happened before the Affordable Care Act,” she told the St. Louis Post Dispatch in an Aug. 2 article. “People will buy a short-term plan thinking it offers good quality coverage, and then be on the hook for tens of thousands of dollars in medical bills when they get pregnant or sick and find out their short-term plan doesn’t cover the care they need.”

Cuba, a broker for the ACA Marketplace, offers hope for ACA improvements in 2019.

“Overall, states in the Midwest will see much lower increases than in previous years,” he said. “In Missouri, companies like Anthem Blue Cross Blue Shield and AmBetter are requesting significantly lower increases. In some cases, customers will see decreases. The market is stabilizing, and that works in favor of farmers and small business owners. There has never been a better time to explore health care options in the ACA.”

One of the benefits of the ACA, Cuba pointed out, is that coverage is guaranteed even if you have a pre-existing condition.

That’s one reason the Marcums said they took the risk of dropping their health insurance.

“I don’t know what I’ll do if I have a heart attack or if one of us gets cancer,” Marcum said. “But since the ACA can’t refuse coverage to anyone, I figure we can sign up during the year-end enrollment period if we need coverage.”

So far, going without health insurance has worked out, he said.

“When we tell doctors we don’t have health insurance, they drop the price of a visit from say $150 to $75,” Marcum said. On the other hand, he pointed out, Tina’s thyroid medication went from $45 a month to $75.

There are other options, Cuba said. Instead of insurance, some of his customers are enrolled in health care cost-sharing ministries.

“People are hearing about these Christian plans from friends and neighbors, and they’re flocking to it,” Cuba said. “Christian Medishare is huge in Missouri—I have 70 customers on it. The plans I work with pay well, and the administrators are friendly, knowledgeable and patient. I’ve heard no complaints.”

These plans are not insurance, Cuba explained. Participants don’t pay premiums—they pay a standard monthly share into a pool. For example, one of Cuba’s customers pays $560 a month in a monthly family share. Administrators provide funds to pay medical bills after they arise.

Still, some farmers delay purchasing health insurance until they turn 65, when they become eligible for federal Medicare coverage. With Medicare, you must continue to pay premiums and deductibles, but plans are generally more affordable than what is available to those under 65.  

In the health care debate, Americans disagree on solutions, and farm organizations reflect that divide.

“We hope to see America’s health care laws changed to provide more competition and bring costs down,” said Eric Bohl, director of public affairs and advocacy for the Missouri Farm Bureau. “Allowing farmers to band together and form their own insurance pools would go a long way toward sharing the risks inherent in farming. Top-down governmental control hasn’t brought down costs. We need more transparency and more options, not more restrictions and mandates.”

Missouri Farm Bureau recently began offering a member-only group health plan for small businesses, including farms, but you need at least two employees to qualify. Cuba Insurance Agency offers similar group health plans for small businesses. However, Inwood said forming farmer pools may prove difficult.

“The average age of farmers at 58.9 makes them subject to higher-cost ratings,” Inwood said. “This, along with farmers’ high risk of injury, will likely make insurance rates high in a farmer-only pool.”

No one can predict what will happen with health coverage—whether the ACA Marketplace will continue, or whether new options will arise for those who can’t find affordable solutions. Congress is considering options to include health coverage in the Farm Bill that expires at year-end 2018. Led by Texas, 20 states are launching legal challenges to the ACA.

In the meantime, Kyle Marcum said he isn’t optimistic about the future of health care for his family and fellow farmers.

“We may look at health coverage again for 2019,” he said, “but we’re waiting for the industry and the politics to settle down.”

For more information, visit the ACA Marketplace at healthcare.gov, or get Medicare info at Medicare.gov. Keep in mind that many health plans require you to make a decision by Dec. 15 for 2019 coverage.