In 2009 Dorothy Bunce had health insurance. She also had all kinds of health problems: Bunce weighed just under 300 pounds, and her high blood pressure, diabetes and the cost of individual private health insurance -- nearly $1,000 per month at its peak -- dictated how she spent her time. Bunce, a 58-year-old self-employed bankruptcy attorney, wanted weight loss surgery but her health insurance company would not even consider covering such a procedure.
After a lot of research into such surgeries and the risks and advantages of going abroad to get one, she assessed the lifetime cost of her health problems. As a bankruptcy attorney, she was well aware of the financial straits that can result from medical debt. So she flew from her home in Las Vegas to Mexico, where she paid for the surgery out of pocket.
One year later, 100 pounds were gone and with it, her high blood pressure and diabetes. Bunce also dropped her health insurance and willingly joined the ranks of the nation's 50 million uninsured.
"It to me was the ultimate 'penny wise and pound foolish' situation," said Bunce. "If my insurance company had been willing to pay, then they could have saved on other medical care costs. But they weren't willing to care, and I wasn't willing to keep paying."
This week, as the Supreme Court hears three days of legal arguments on the constitutionality of the Affordable Care Act, the stories of people like Bunce, who eschew health insurance, and those who desperately want it have hovered in the background. On Tuesday, the legal debate centered on whether the government can compel people to buy health insurance, the so-called individual mandate. Today, the court will consider whether the law can still stand in the potential absence of a mandate and whether plans to expand access to public health insurance programs overburdens states, which will eventually have to share in some of the added costs.
Should the Affordable Care Act withstand the legal challenges before the Court, in 2014 it will expand access to public health insurance programs and outlaw the practice of charging some people more than others. An estimated 30 million people who are uninsured today would have a more secure and less costly path to health care.
"What health care reform does is take a lot of the uncertainty out of the process. It would make health insurance portable and more affordable for a lot of people," said Edwin Park, a vice president for health policy at the Center on Budget and Policy Priorities, a Washington, D.C.-based think tank that examines the impact of domestic policy and spending.
The law would also require most Americans either to enroll in expanded public health insurance programs, like Medicare, or to purchase private health insurance, for which federal subsidies would be available for some. Proponents of the two-year-old law insist that without the mandate, the entire raft of health care reforms will simply sink.
Critics say the individual mandate takes the unprecedented step of forcing Americans to purchase a product whether they want it or not.
"What we know about the individual mandate for sure is that it will bring additional people into the system and it increases revenue for the insurance companies," said Douglas Holtz-Eakin, an economist and former director of the Congressional Budget Office who served as a chief economic policy advisor on John McCain's 2008 presidential campaign.
Holtz-Eakin sat in on the Supreme Court's hearing on Tuesday, when a legal brief that he helped to draft in opposition to the mandate was mentioned. Holtz-Eiken's essential argument: Congress does not have the authority to force Americans to purchase a commercial product. That is particularly true when the requirement imposed by Congress will do little to control actual health care costs, he said.
Different types of health insurance at different price points could help more people become insured, he said. Holtz-Eakin declined to comment on where this range of products would likely leave the 50 million people who are currently unable or unwilling to pay for health care.
The day Bunce bought her individual insurance policy in 2005, the agent looked at the weight listed on her driver license and warned her: The policy she was considering would never cover weight loss surgery. It was an uncomfortable conversation, she said.
At the time, Bunce had just turned 50. She had tried conventional weight loss methods for decades, even enduring a program that had her visit a doctor's office for daily weigh-ins and kept her on an extremely restricted diet. Nothing had produced lasting results. But Bunce was shopping for an individual plan that would cover all sorts of doctor visits and prescriptions at a price that she could afford. Save the weight loss surgery provision, this agent had what she needed.
By late 2009, Bunce had made up her mind. She was paying nearly $600 a month in health insurance premiums and about $350 each month in co-pays for the prescription drugs that managed her blood pressure. In December, Bunce flew to Tijuana, Mexico, and paid $7,000 to a private health care facility, where a surgeon installed a lap band, a device that closes off a portion of the stomach.
Bunce shed 60 pounds in four months. Then Bunce suffered a setback when her body rejected the device, which happens more often to people with her blood type. Bunce's doctor also thought all the crunches she had been doing might have moved the device out of place. After a second surgery in Mexico to remove the lap band and a third to reduce the size of her stomach without a device, Bunce lost and kept off another 40 pounds.
Bunce’s blood sugar and blood pressure stabilized, then fell into normal ranges, rendering her prescriptions unnecessary.
But in 2010 the economy in foreclosure- and unemployment-addled Las Vegas was still sputtering. The "Walmart of bankruptcy law firms" came to town with a huge advertising budget that made life even harder for attorneys like Bunce. Her business slowed down so much that it grew difficult for her to pay the $800 per month insurance premium. She cut employees and started renting out office space to other lawyers.
"It basically got to the point where I had to make a choice between paying the rent or paying the medical insurance," said Bunce. "I chose rent."
Bunce would prefer never to do business with a health insurance company again. Bunce's opinion developed through her own experience and after seeing a large number of her clients, insured and uninsured, brought to the brink of financial collapse because of health care bills, she said.
"They have proven themselves unwilling or unable to provide honest services in the marketplace," she said.
If Bunce needs serious medical care in the future, she will head back to Mexico, she said. Still, Bunce does not count herself among those who are opposed to health care reform. She's part of the camp that thinks the Obama administration's health care reforms did not go far enough.
"I would have liked to have seen truly socialized medicine," said Bunce.