For nearly two decades, Barbara Garnaus maintained a modest, delicate life balance: keeping her part-time Orange County school district job and juggling her bills and credit card debt.
Now 63, living alone, she counts every dollar, has no cellphone and commutes an hour in traffic so she can keep an affordable apartment in Laguna Woods.
Having good health helped. Garnaus got by without medical insurance, relying on yearly exams at a free clinic. But that changed last year: Garnaus now needs treatment for cancer, and she bought insurance under Obamacare.
Thousands of Californians like Garnaus are poised to reap significant benefits from the nation's healthcare overhaul: access to levels of service and treatment previously out of their reach, and government subsidies that bring down payments dramatically. Still, Garnaus is anxious about taking on even modest additional monthly costs.
At the margins of poverty, even committing to premiums, co-payments and other new medical expenses of hundreds or a few thousand dollars a year can be difficult to manage, according to researchers and groups working with the low-income patients now required by federal law to buy insurance.
"When you talk about paying for something on a monthly basis like that, it's something very real that people have to consider," said Kandis Driscoll, a manager with the Santa Monica-based Insure the Uninsured Project. "It could be a survival decision."
Price was Garnaus' overriding consideration in choosing a policy.
"I got the cheapest one, the very cheapest one," she said. "And for me it's still not cheap."
As she reviews invoices at her desk, the tail of a blue scarf wrapped around Garnaus' head brushes her shoulder. Tacked to the wall behind her are photos of her with former colleagues and an old yearbook portrait showing off the wavy blond hair she lost to chemotherapy last year.
She works 20 hours a week ordering pencils and testing materials, earning $22,480 annually before taxes, and isn't eligible for the district's health insurance coverage. She's tried unsuccessfully to get full-time work at the district and elsewhere, she said, but felt it was best to hold on to what she had when the recession hit.
Her monthly take-home paycheck is about $1,750. With her $1,180 rent, about $150 on gasoline and $100 on utilities, she's left with less than $320 each month for food and any other expenses, including medical bills.
In March of last year, Garnaus was diagnosed with a rare but aggressive uterine cancer. She initially received treatment through Orange County's taxpayer-supported healthcare program. She qualified for the low-income program because her earnings fell below the $22,980 annual ceiling the county had set for a single-person household, roughly 200% of the federal poverty level.
When that county program expired Dec. 31, most of the patients transitioned to Medi-Cal, the state's program for the elderly and poor. But Medi-Cal covers people only up to 138% of the poverty level — $15,800 for a single person — which disqualified Garnaus.
Garnaus acknowledges that insurance will be good for her health and finances in the long run but says she's barely able to cover the increased monthly costs. With government subsidies, her monthly insurance premiums are $13.50, and co-pays to see her oncologist are $20. When lab work or a CT scan is required, it can cost up to $100 more.
"I'm continuously getting into debt," she said. Under her plan, she says, she can have up to $2,250 in annual out-of-pocket payments.
During a workday lunch break last month, Garnaus said she was contemplating skipping CT scans recommended by her doctors because of the added cost. "It's a very scary situation," she said.
Jennifer Tolbert, director of state health reform at the Kaiser Family Foundation, a healthcare research group, said that previously uninsured patients living on the cusp of poverty and now required to buy insurance may struggle with the new financial obligations but should focus on the upside.
"These individuals will pay more," she said, "but they will get better benefits."
In February, Garnaus saw her oncologist for the first time with her new insurance. She cringed at the $20 co-payment and $15 for lab tests.
But she was thrilled days later when the results came back. "I'm crystal clear, just clean as a whistle, thank God," she said.
Recently, a friend who also has uterine cancer told Garnaus that a CT scan was the only thing that caught a resurgence of her disease.
Now, Garnaus feels increased pressure to get a scan. She says she's just not sure where she'll get the co-payment.
"That's the $100 I don't have," she said.