I have spent several hours on the phone with Humana and Healthcare.gov and burrowing into the weeds of the insurance plan I proposed to buy. The news is not good. (More)
Like many Americans, I was thrilled at the prospect of finally having health insurance after so many years without. While I wasn’t exactly thrilled with my limited options because of my income, it was still better than nothing. I was so convinced of that that I refinanced my house so I would be able to pay an insurance premium.
Then I started looking more closely. Right about the time I was finishing my application with Humana, it told me to select my provider. I started optimistically, because I had found my doctor listed as in-network with Humana. Well, on the list of doctors they gave me, he was conspicuously absent. So I called Humana and was told that he was in-network by not my network. I would have to get a different primary care physician. That upset me, but finally I moved ahead with the application. I reached the point where I had to set up payment and came to a dead halt.
First of all, they warned me there would be an additional charge if I didn’t arrange for a direct debit to my bank account. I wanted to find out what this charge would be, but the link drew a blank. Now I was getting nervous. I clicked on the link for plan details and it, too, came up blank. All of a sudden I felt like I was buying a pig in a poke.
So back to healthcare.gov to find out what details they had on this plan. That’s where things got really interesting.
1. No out-of-network provider would be paid anything, including doctors you saw in an in-network hospital. Nor would the cost of seeing them count toward your out-of-pocket or deductible.
2. You are allowed to visit the doctor’s office only three times a year, whether for illness or well checks.
3. None of the copays or coinsurance that I would have to pay would count toward my deductible or my maximum out-of-pocket. This becomes important because when you hit your deductible, you start paying coinsurance… which won’t count toward your maximum out-of-pocket.
4. One of the most important drugs I take would not be covered until I met my deductible, which is apparently impossible when none of your copays or coinsurance payments count toward it. And while we’re at it, my copay on generic drugs would increase my drug cost by 7 times (from $4 for a generic to $28).
5. Once I have insurance, I might no longer have access to patient assistance to get my most expensive drug. Currently I receive it free from Merck. Once I have insurance, a question has arisen. At some point some lawmaker or rule maker decided that Medicare recipients were ineligible for patient assistance, as it constituted a “kickback.” I’m not sure how they reached this conclusion, but patient assistance programs are worried this will fall into that same claim of a kickback. HHS said it won’t because plans obtained through the exchange are private, but another agency said yes. Lawyers are arguing, but in the meantime I might not be able to get that drug, which even discounted amounts to $320 per month.
In other words, this insurance plan won’t pay a penny for anything until I reach my individual deductible of $6300/year. The only way that could happen is if I had a serious emergency hospitalization. So I, and the government, will be paying Humana $11,400 per year for nothing except an insurance card.
So here we are. Every possible out for the insurance companies has been found. If you can afford a much more expensive plan, you will probably get better coverage, but even that is limited. And of course, with all the things that don’t count toward your maximum out-of-pocket expenses, the cost of care will be much higher than what you expect.
People in the median and lower income groups are about to become national guinea pigs. If they get really sick and wind up in a hospital, some may still go bankrupt. Most people at this income level don’t have enough savings to cover the deductible and annual out-of-pocket limit.
I spoke to a navigator at healthcare.gov about all of this, and the only help he could offer me was to try to buy a more expensive plan. Even at the silver level, if I could afford it, I would face most of the same problems. I told him to be sure to pass this up to the policy and rules people, because this game is now rigged, and the way it’s rigged could destroy the ACA.
Then came the good news. He explained that all of this is very new, and HHS expect that premiums will decline and benefits will improve next year. That’s because of the “risk corridors” built into the ACA. Insurance companies that make huge profits will pay into a government fund to underwrite insurance companies that take big losses, and on Tuesday the CBO estimated that the government will recover about $8 billion from that fund over the next three years. HHS expects insurance companies will adapt their policies, with lower premiums and improved benefits, because any excess profits will go to the government anyway.
Of course, Republicans want to end those “risk corridors,” letting lucky insurance companies keep excess profits and unlucky companies stick customers with unpaid claims.
I think the ACA will become a very good law. But we’ll have to elect leaders who will protect it from the insurance companies.