From Despair to Hope
Ten years ago, Darrin Richardson was diagnosed with emphysema. Fighting an incurable lung disease was a familiar battle for him. His daughter, Clarissa, then 14 and living with her mother in New Jersey, had severe chronic bronchitis and had struggled with it ever since she was born.
While separated by state lines, the two had a common bond, sharing similar and often debilitating symptoms. Constant wheezing and coughing were considered normal for the two. Everyday living could be a struggle. Chores around the house were exhausting. Breathing was hard. But each day for the next seven years, Richardson would get up and go to his job as a manager for IHOP, tending to the staff and cooking in the kitchen. In 2007 everything stopped.
Richardson’s health had deteriorated so badly that his doctor told him he would die without a double–lung transplant. Until he could receive the surgery, he would need to walk around with an oxygen tank, a major fire hazard in the IHOP kitchen. Unable to perform his daily duties, Richardson was soon out of a job. The kicks kept coming when he lost his home to a fire in 2008.
Around the same time, his daughter’s health also had spiraled out of control. Her strength was gone. Her breathing labored. Her 21–year battle with lung disease was coming to an end. She died on August 16, 2008.
The 20 Percent
In the span of about a year, Richardson had lost his job, his health insurance, his home, and most precious of all, his daughter. The only thing he felt he had left to fight for was his life, and he couldn’t even afford it.
Without employment prospects, Richardson applied for both Medicare and D.C. Medicaid. His caregiver Stephanie Wilson helped Richardson line up Medicare as his primary insurance and D.C. Medicaid as his secondary insurer.
Soon after Medicare approved his surgery, Richardson made an appointment with Inova Fairfax Hospital. Medicare only pays 80 percent of the double-lung transplant, hospital staff told him. Get D.C. Medicaid to look at your case and make sure you’re approved for the rest, staff suggested. He was not.
D.C. Medicaid denied his request, citing the fact that its plan states specifically that it does not cover lung transplants. “I thought I was going to die. There was nobody to help me. They told me I had to move to Virginia or Maryland to get this operation done because D.C. Medicaid was not going to pay the 20 percent,” Richardson said.
The transplant itself was going to cost an estimated $807,000, but when it was all said and done, his surgery would total nearly $1 million. Twenty percent of $1 million was insurmountable. Where would the money come from?
Improving Access to Health Care
In 2008 the D.C. Bar Pro Bono Program’s Health Care Access Project (HCAP) was created to help low-income District residents receive legal representation when they are being denied health care, including medical treatments and medication, due to problems with obtaining pre–approval from insurance companies or unsatisfied medical debt.
“We understood how important this work would be for our clients, to have a lawyer help them access necessary medical care,” said Mark Herzog, associate director of the D.C. Bar Pro Bono Program. “We never imagined that our lawyers would literally be saving lives.”
According to Statehealthfacts.org, a project of the Henry J. Kaiser Family Foundation, 40 percent of the low–income adult population in the District was on D.C. Medicaid in 2009, while 28 percent had no coverage at all.
Even those with insurance are often weighed down with medical debt because certain medications or treatments are not covered. Without pre–approval, many poor patients must forego treatment. In Richardson’s case, sacrificing treatment meant sacrificing his chance to live.
As part of the program, HCAP offers lawyer training that explores a wide range of advocacy strategies for people with no health insurance, public health benefits, or private insurance, or who have medical debt, or who are being denied insurance coverage for treatment. By participating in the training, attorneys agree to take two cases through HCAP.
A Personal Fight
Allison Highley, a federal contractor for the Centers for Medicare & Medicaid Services, was among the lawyers who participated in one of the training sessions. For Highley, health care access is a very personal cause. Her father died in August 2011 with no health insurance.
“He worked his whole life, but … at some point, his health was so poor, he couldn’t work without putting himself in the hospital,” she said. “About a year ago, he couldn’t do it any more.” Her dad lost his insurance because he didn’t have a job. He was too young for Medicare. His unemployment benefits prevented him from qualifying for income–based benefits. His prescriptions alone were more than $1,000 a month, and his doctors couldn’t see him if he couldn’t pay.
“There are safety nets in place only if you’re old enough or only if you’ve spent all of your money and all of your family’s money, and you’ve sold everything,” Highley said. “A lot of times, I encounter people with federal jobs or jobs where health insurance is just a benefit they have. They’ve never known what it’s like to have to pay those expenses. It’s inconceivable to them that somebody wouldn’t have health insurance. I get a lot of, ‘Oh, people who don’t have health insurance are deadbeats,’ and that’s not true. Bad things happen to everybody…. The safety nets don’t always fit.”
To help those who fall through the net navigate the complicated health care process, Highley signed up for HCAP training in February 2011. A few weeks later, Richardson’s case came across her desk.
One Year to Live
Six months prior to meeting Highley, Richardson was told by his doctor he had 18 months to live. Now, it was under a year. “He was very down. He was depressed. You could feel it. He had almost lost hope,” Highley said. They sat down and discussed the situation and what his eligibilities were.
“I knew I had a chance when I met her. She was going to do everything in her power to make it happen,” Richardson said.
“I did tell him, ‘You know, if there’s no coverage, then there’s no coverage,’” she recalled. “‘If there is something, then we’ll find it, and we’ll fight to get it for you.’” And there was something. While poring over the pages of the D.C. Medicaid plan, she found a very specific provision. Lung transplants are not covered under D.C. Medicaid unless there is additional coverage by another health care provider.
“If you’re dual–eligible [Qualified Medicare Beneficiaries], the Medicaid agency will pay the deductible and coinsurance amounts for all services available under Medicare, with no exceptions or anything,” Highley said. Richardson fit the bill.
During a status conference over the phone with counsel from the D.C. Department of Health Care Finance, Highley read the provision she had found. A few hours later, opposing counsel called her back, stating that they had reevaluated the case and she was correct. A few days later, the department issued a letter signed by the director of Health Care Finance saying that D.C. Medicaid would cover its 20 percent of Richardson’s procedure.
She immediately called Richardson. “I jumped for joy and cried,” Richardson said. “She came through like she said she would. It’s a blessing.”
Added Highley, “It was just one of those moments. We couldn’t believe it. It was really amazing,” Highley said. “It was just the best moment, just the best moment.”
On September 27, 2011, Richardson was officially placed on the waiting list for a double–lung transplant and is waiting for the call.
“These situations are literally life and death. It’s such a small amount of commitment on our part,” said Highley, encouraging other lawyers to join the effort. “It was just over 14 hours of actual time working on the case. It was six weeks. In six weeks, we saved his life.”
Want to Get Involved?
For information about upcoming trainings, please visit our web site.
The Health Care Access Project is now part of the D.C. Bar Pro Bono Center's Advocacy & Justice Clinic. For information about volunteering with the Advocacy & Justice Clinic, please contact managing attorney Adrian Gottshall by email or phone at 202-780-2744.
By Thai Phi Le
From Washington Lawyer, February 2012
Reach D.C. Bar staff writer Thai Phi Le at [email protected].
