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Insured, But Not Covered: The Problems With Obamacare

The Affordable Care Act may in some ways be undermining its signature promise: health care that is accessible and affordable for all.
Insured, But Not Covered: The Problems With Obamacare
Image from: Christiana Care

Let me put it this way: I'm not at all surprised. I continue to be surprised, confused, and angered by the additional charges and co-pays through my Obamacare policy, all of it grounded in the long-disproven zombie idea that just will not die among elite policy circles: That healthcare users "need to have skin in the game," because God knows, everyone will be running off to the doctor and scheduling unnecessary surgeries and treatment just because they can!

I have said all along that a substantial number of voters were pissed off about this, and the Democratic candidates bragging about Obamacare without acknowledging its problems didn't help. The Dems should have run as "the party that's going to fix the Obamacare problems." But they didn't.

Read the whole piece, because it details why so many people who love Obamacare also hate it. Elizabeth Rosenthal, in the New York Times:

The Affordable Care Act has ushered in an era of complex new health insurance products featuring legions of out-of-pocket coinsurance fees, high deductibles and narrow provider networks. Though commercial insurers had already begun to shift toward such policies, the health care law gave them added legitimacy and has vastly accelerated the trend, experts say.

The theory behind the policies is that patients should bear more financial risk so they will be more conscious and cautious about health care spending. But some experts say the new policies have also left many Americans scrambling to track expenses from a multitude of sources — such as separate deductibles for network and non-network care, or payments for drugs on an insurer’s ever-changing list of drugs that require high co-pays or are not covered at all.

For some, like Ms. Pineman, narrow networks can necessitate footing bills privately. For others, the constant changes in policy guidelines — annual shifts in what’s covered and what’s not, monthly shifts in which doctors are in and out of network — can produce surprise bills for services they assumed would be covered. For still others, the new fees are so confusing and unsupportable that they just avoid seeing doctors.


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It is true that the Affordable Care Act has erased some of the more egregious practices of the American health insurance system that left patients bankrupt or losing homes to pay bills. Insurers can no longer deny coverage to those with pre-existing conditions, for example. And the new policies cap out-of-pocket spending so long as the patient receives care within the plan. Most important, the act has offered health insurance to an estimated 10 million Americans who did not have any, often by expanding Medicaid or providing subsidies.

But by endorsing and expanding the complex new policies promoted by the health care industry, the law may in some ways be undermining its signature promise: health care that is accessible and affordable for all.

“I’m always curious when I read this ‘good news’ that health costs are moderating, because my health care costs go up significantly each year, and I think that’s a common experience,” said Mark Rukavina, president of Community Health Advisors in Massachusetts.

While much of the focus in the past has been on keeping premiums manageable, “premiums now tell only a part of the story,” Mr. Rukavina said, adding: “A big part of the way they’ve kept premiums down is to shift costs to patients in the form of co-pays and deductibles and other types of out-of-pocket expenses. And that can leave patients very vulnerable.”

Such policies desperately need improvement, patients and professionals like Mr. Rukavina say. But with the Republicans attacking the Affordable Care Act at all turns, even political supporters seem reluctant to acknowledge that it has some flaws. The narrative has been cast in black or white: It’s working, or it’s a failure. The reality, of course, is gray.

AT this point, we don’t have a good definition of “affordable” — or how to measure it fully and fairly. Many studies show that national health costs, while still rising, are not growing as fast as they once were. But what does that mean for individual patients? So far the research has yielded mixed results.

A study by the Commonwealth Fund this month found that the rise in health insurance premiums in employer-based plans had slowed in 31 states since the passage of the Affordable Care Act (good news, right?). But premiums were still rising faster than median incomes (hmm). More important, perhaps, the researchers found that patients were paying more in health care expenses than ever before, during a time of stagnant wages (not so great). In fact, nearly 10 percent of median household income now goes to pay premiums and deductibles, the study found. And that does not include other kinds of health payments that patients now encounter, such as co-pays and uncovered drugs or services.

A recent New York Times/CBS poll found that 46 percent of Americans said they had trouble affording health care, up 10 percentage points in just one year. Some of the cost problems may ease as patients — now known as health care consumers — learn what to expect and how to choose and navigate their plans.

But other problems may be related to the process by which the plans are created. Under the Affordable Care Act each state was asked to select a benchmark plan as its standard. It had to cover certain “essential health benefits” like maternity care and prescription drugs; it had to have a defined actuarial value depending on the level of plan. Silver plans, for example, had to cover 70 percent of charges, leaving consumers with 30 percent. But within those parameters, competing insurers had leeway to set premiums, co-payments and deductibles, and to create networks by negotiating with doctors and hospitals. Naturally, they created policies that met the core criteria while minimizing their financial risk.

Suddenly there were hundreds of new insurance products that had never been tested in real time. Their shortcomings are now playing out in various ways.

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