A Swansea woman's health insurance saga: Breast cancer leads to bankruptcy

SWANSEA — A routine mammogram a year ago — Angie Salvador's first ever — launched her on an odyssey through the American healthcare system.

More tests were ordered. A biopsy followed. Then the bad news: breast cancer.

She began a hormone treatment to halt the spread. In December of last year, she underwent a double mastectomy and reconstructive surgery at Barnes-Jewish Hospital.

By then, the bills were already filling her mailbox in Swansea.

Salvador, a 42-year-old social worker in East St. Louis, had health insurance. But with an out-of-pocket maximum of more than $8,000, the bills not covered by insurance for treatments, diagnostics and surgeries strained her $42,000 salary.

When the new year started, her deductible and $8,200 out-of-pocket maximum reset, just in time for more bills from procedures due to complications from her reconstructive surgery.

She was already struggling with some medical debt. In September, Washington University Physicians sued her for $1,916 in St. Clair County, leading to an order to garnish her wages.

On top of her battle with cancer and the resulting medical bills, another shoe dropped: Her health insurance premiums skyrocketed at the beginning the year, rising from just more than $100 per paycheck to $450 per paycheck, according to pay stubs she shared with the Post-Dispatch.

Some of the increase was because she'd recently married and added her husband to her health insurance plan at the beginning of the year. But some of the increase is also due to the expiration of federal enhanced tax credits that subsidize premiums for insurance plans on the Affordable Care Act exchanges, where Salvador buys her insurance.

Democrats in Congress shut down the government for weeks last year over Republicans' refusal to extend the healthcare subsidies, warning the expiration would lead to steep insurance hikes for millions of Americans.

Salvador, it seems, is one of them. She's also a stark example of the financial strains a chronic illness, even for those with health insurance, can have on low- and moderate-income families.

About 4 in 10 Americans have debt related to medical bills, according to the nonpartisan healthcare policy nonprofit KFF. Just under half of adults recently told KFF pollsters it is difficult to afford healthcare in the U.S.

"Those who are covered by health insurance are not immune to the burden of health care costs," KFF said in a brief from April.

Salvador was caught in a system where she made too much to qualify for Medicaid, the healthcare plan for the poor, but too little to afford the high costs of healthcare.

In March, she filed for bankruptcy, the only way she saw out from the $8,400 in new medical debt — which had piled on top of $5,800 in existing medical debt from another hospital for past treatment of Parkinson's disease.

"Our cars are paid off," she said. "I have one credit card that I pay off every month if I use it, and we just, we live within our means. But it wasn't possible to do that when it came to my cancer."

'A sicker, smaller pool'

Salvador and her husband, Celerino, rent a modest house in Swansea, where their backyard has room for a garden and two dogs, Kima and Canellita.

With their household income of $73,000 — roughly the median in St. Clair County — it would already have been a strain to pay the hospital bills from Angie's cancer treatments and surgery that her insurance doesn't cover.

The expiration of federal support for insurance plans purchased via the Affordable Care Act made it impossible. She saw the impact on her paycheck right away, as the amount taken out for health insurance jumped to $450 a paycheck, versus $100 last year.

She expected an increase in her health insurance premiums when she added her husband, who works as a handyman and at a restaurant. But not this much.

"It's like I'm getting a part-time salary," she said.

Her employer, a small social services agency, had contributed $500 per month to her purchase of a health plan on the ACA exchanges. It upped its contribution to $750 when she switched to family coverage to include her husband.

Her combined monthly premium last year, including her employer's contribution, was around $700. This year, it jumped by about $1,000, to more than $1,650.

Not all of that can be attributed to the addition of her husband, said Tim McBride, a professor of healthcare economics and policy at Washington University.

"That's really way more than what we're seeing on average," he said.

Since the expiration of the premium subsidies, at least 1.2 million fewer people signed up in 2026 for health insurance through the ACA, a 5% drop from last year, according to figures from the Centers for Medicare and Medicaid Services.

Preliminary data from CMS, and analyzed by McBride at WashU, show the average marketplace plan's premium increased 20%, to $741 per month. The average out-of-pocket costs rose over 50% when the loss of the federal subsidies are taken into account.

In Illinois, average monthly premiums on the health insurance marketplace rose 21% this year, to $816; the number of people enrolled fell almost 4%, to just under 450,000. The average out-of-pocket cost after subsidies rose 20%, to $230, according to CMS data.

In Missouri, average monthly marketplace premiums increased 17% this year, to $724. The average out-of-pocket costs after subsidies nearly doubled, to $173. About 50,000 fewer people in Missouri signed up on the exchange, a 12% decline.

The decline in Americans signing up for insurance on the exchanges could end up being far larger, according to the Commonwealth Fund, a nonpartisan health policy outfit. In an article published this month, Commonwealth cited estimates predicting enrollment would fall by as much as 5 million people, or around 20%, as premiums come due and people either can't pay them or decide not to.

The drop is fueling some of the premium hikes by participating companies, McBride said. People who can afford to drop coverage are often younger and healthier. Many of those who stay, like Salvador, need the insurance to cover chronic conditions.

Insurers are "left with a sicker, smaller pool, so they want to raise their premiums to account for that," McBride said. "We have overall inflation going on in health care of maybe 5% to 7%, so I wouldn't have been surprised if it were somewhere around that. But 20% was a pretty big number."

'It seems unsustainable'

The jump in Salvador's premiums at the beginning of this year came as she was already drowning in bills.

She had accrued about $5,800 in debt from HSHS Medical Group, the Central Illinois hospital system, for treatment of her Parkinson's. She also has over $30,000 in student loans as she works to finish her master's degree in social work through the University of Illinois. Student loans, unlike most debt, aren't automatically expunged via bankruptcy.

Beyond those obligations, she had no other debt, according to her bankruptcy filing in March. The more than $6,000 in bills from BJC since her breast cancer diagnosis — last summer, she also had two emergency room visits at Memorial Hospital in Belleville, part of BJC — and the Washington University Physicians collections lawsuit pushed her over the edge.

She paid a few hundred dollars here, a few hundred there. But she couldn't keep up.

When she picks up overtime, a couple hundred dollars is eaten up by the wage garnishment from Washington University Physicians, she said, pointing to a recent pay stub showing a $270 garnishment.

Salvador decided bankruptcy was her best option. In her filing, she listed $51,000 in total debt: $37,000 in student loans, and $14,000 in medical debt.

Much of her medical debt, she said, was for a surgery that wasn't even successful. Her reconstructive surgery post mastectomy led to complications. In January, she had to have another surgery to remediate problems from the reconstruction.

"I have no reconstruction," Salvador said.

In a joint statement, Washington University Physicians and BJC said they can't comment on an individual patient's case because of health privacy laws. But they noted that patients can apply for financial assistance.

"BJC and WashU Medicine are committed to ensuring our patients have the support they need to navigate their care and their bills," the statement said. "We encourage all patients with questions or concerns about their bills to contact us directly so we can help them understand their options."

Salvador's income has dropped so much that she qualifies for Medicaid now, which she signed up for as supplemental insurance. But that created another issue: When she showed up to the Barnes-Jewish Center for Advanced Medicine for a round of chemotherapy last week, she was told her primary insurance through the marketplace was no longer active, even when she tried to explain she had just paid a premium for it. She was turned away.

She spent the next 36 hours calling Blue Cross Blue Shield, her insurer, and BJC to iron out the issue. She is now scheduled to begin radiation this month.

Salvador has other chronic health conditions: Parkinson's and Crohn's. Between that and cancer treatment, she feels she may need to find a job simply for better insurance coverage, maybe through state government. But her current job gives her enough flexibility to take classes and finish an internship for her master's degree.

"I love my job; I love working in East St Louis. I mean, I truly, truly do," she said. "But it seems unsustainable if I had to declare bankruptcy because I got cancer."

For now, she is mostly focused on making it through each day of work amid cancer treatments while navigating a complex web of insurers, hospitals and doctors.

"I'm assuming that you can get excellent quality healthcare in the United States," Salvador said. "I just don't know anybody that's able to afford it."

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