A fall through insurance-coverage gap
Phil Venezio worked for 30 years before he got sick and lost his health insurance. The he missed qualifying for Medicaid by $77.
MAYS LANDING, N.J. - Phil Venezio worked for 30 years selling laboratory equipment to schools and industry. He supported a family, paid taxes, saved what he could.
Last year, illness and disability overwhelmed him so fast, at age 55, "it felt like a dream," he said. "Could this be me?"
He couldn't work, lost his job, and with it, his health insurance. Venezio now receives $1,988 a month in disability from Social Security, which he paid into all his adult life. This is not enough to afford private health insurance for him and his wife, Kathy, he said.
The State of New Jersey denied him health insurance under Medicaid, a safety net for the poor.
The maximum income allowed is $1,911 a month.
He's $77 over the limit.
So he has no insurance.
"They're penalizing me because I've worked hard and paid into Social Security all my life," he said. "That part kills me the most."
"It's pretty surprising in a year's time," he added, "how you can go from successful to nothing."
Venezio worked for a variety of companies over the years, selling countertops, cabinets, sinks, fixtures - everything a company or school might need for a lab.
He made a middle-class living, $60,000 to $90,000 a year, he said.
His wife works part-time at a clothing store near the Hamilton Mall and makes enough pocket money to buy their weekly groceries, he said. She also spends a lot of time attending to his medical needs.
On Nov. 18, 2007, getting out of bed, Venezio couldn't stand up. He'd been complaining of pain for months. Doctors found a mass on his spine, which turned out to be an infection, he said, "that ate away at the bone, which caused the bones to rub, resulting in extreme pain."
After treating the infection, surgeons "inserted titanium rods and screws to rebuild my damaged spine," he said.
The infection and surgery left him in a wheelchair with nerve damage and a 30 percent chance of walking again. He needs a catheter because he no longer can control his bladder.
When he could no longer work, his employer offered him the option - required by law - to continue his company health insurance for 18 months. But that cost $1,097 a month. He couldn't afford it.
He has spent about $12,000 out of pocket, he said, and his savings are nearly gone. He also owes more than $7,500 in medical bills, and creditors are calling.
He dialed 211 in Atlantic County, a human-services hotline.
He was referred to Mason Meltzer, a social worker with the Department of Intergenerational Services.
Meltzer could not speak about Venezio, citing privacy. But when asked whether he has many clients who make too much to qualify for Medicaid, but can't afford insurance themselves, he cited the nation's economic troubles and replied:
"We have a big, big problem and it's about to get much, much worse."
Venezio applied for a Medicaid program called Global Options Nursing Facility Transition. This is designed to keep people out of nursing homes and in their own homes.
This program has the highest income eligibility limit of any welfare program, $1,911.
Venezio was denied on June 30.
"Client found financially and medically ineligible for Global Options," said the letter from the county's Medicaid Long Term Care Unit.
Venezio appealed in person.
He summarized his argument: "I'm crippled and in a wheelchair. There's nothing more that I'd like tomorrow morning than to get up and be a positive person in the workforce and go to work. But I could not function. I could not do what I did in the past. I don't want to be on disability and in this situation. It happened and I'm dealing with it. All I'm trying to do basically is to exist. I've worked hard all my life. And I don't feel that $77 should be a determining factor whether I get Medicaid or not."
Venezio expects a ruling any day.
But the state's expert on Medicaid eligibility, Elena Josephick, who runs the Medical Assistance and Health Service division in the Department of Human Services, said the $1,911 limit is "hard and fast."
"It's an income established by the federal government," she said.
Venezio also applied for another Medicaid program, Medically Needy, which in some cases will pay medical bills. But he would have to pay at least the first $10,000 in unpaid medical bills. This fall, Venezio sought legal assistance from the Community Health Law Project, a nonprofit that helps disabled New Jersey residents navigate the insurance maze and get coverage. It couldn't represent him.
"He is over income for our program, too," said Brian Smith, a senior staff attorney. "Take that for working all of your life!"
When he called the hospital to say he just couldn't pay his bills, Venezio was referred to the Charity Assistance Program at AtlantiCare Regional Medical Center in Pomona. He was approved for 100 percent coverage of hospital costs until Dec. 31, when he must reapply.
Venezio goes there for tests and to have his catheter replaced monthly.
In terms of trying to get outpatient physical therapy, Sandy Gubbine, director of patient accounts at AtlantiCare, had this advice for Venezio:
"Contact facilities and wheel and deal. It's like buying a car. Compare and try to get the best deal. If you're uninsured, that's where you are in the health-care arena."
Venezio's struggle for health insurance should end in 2010 - that's when he will be eligible for Medicare, the federal health-insurance program for the elderly and disabled.
When Congress expanded Medicare in 1972 to cover the disabled as well as people 65 and older, it established a two-year waiting period to keep costs down, according to the Medicare Rights Center.
At any one time, a spokesman said, about 1.5 million Americans are in this gap - eligible for disability, but waiting for Medicare. About 25 percent are like Venezio - without any health insurance.
Venezio is still dizzy from the way his life turned around.
"This whole situation kills me," he said. "I've always worked for everything I got. If I could get out of this wheelchair and dig holes to make money, I'd do it. Tomorrow."