Is health insurance the new paternalism in health care?


If I could drop our health insurance altogether, I would. With a high deductible of $4,000 for in-network providers, my family of three has yet to reach our collective deductible over the last three years. This means we have to pay out of pocket for medical care until we reach that amount. To make matters worse, our health insurance premiums increased by 10 percent, forcing us to find a less expensive plan. However, our new plan, now with a different company, is consistently denying coverage for medications we have been taking for years.

Our daughter has been the hardest hit in our family so far. She has a medical condition for which she uses a transdermal form of a medication because the oral form causes her serious stomach problems. The patch is brand and it does not come in a generic. Our new health insurance company required a preauthorization for the medication, even though our last health insurance plan approved it. Her physician submitted the forms and approval was denied based on their requirement that she had to try three other “preferred” medications before they would consider approving the medication she’s been on since 2011. She did try three other medications on their “preferred” list several years ago before settling on the patch.

Her physician had to re-submit the pre-authorization forms, highlighting the three medications she tried in 2011. Three weeks later, we are still waiting for approval. I will have to file an appeal or complaint if her medication continues to be denied. In the interim, I found a discount coupon on the drug manufacturer’s website that cut the cost of her medication in half, which allowed her to continue the medication for another month.

I thought the Affordable Care Act (ACA) was supposed to make health care more affordable but it appears that costs are being shifted to patients. Insurers limit their expenses by creating tiered drug lists. Patients pay much less for generic and brand name drugs on the health plan’s formulary. If the medication prescribed for a patient is not on the formulary, a preauthorization has to be submitted and if denied the patient pays quite a bit more out of pocket. The patient also has the option to take a different medication that the insurer suggests, not one recommended by his or her physician.

In a new report from the New England Journal of Medicine, 12 out of 48 examined health plans offered through federal exchanges were found using adverse drug tiering for the most costly medications. If insurers place certain drugs in the highest cost-sharing tier, making them the most expensive and least accessible to patients, are insurers discriminating based on what is least expensive to them?

Sandra is in a similar situation with her insurer’s denial of a sleep medication she’s been taking for years. Recently her health insurance plan (one she’s had for many years) informed her that the prescribed medication that was previously covered is now excluded from her plan. As a substitute, they offered a completely different medication, one that is used off-label for sleep but is actually an antidepressant. She said to me, “Health insurance companies have all the power. They are the new bully on the block.”

Costs seem to be shifted to patients in other ways too. Even plans purchased under the ACA will face substantial price increases this year, as much as 20 percent

High-deductible plans under the ACA now dominate open enrollment. High-deductible health plans are more affordable for employers and can appear that way for individual subscribers because of cheaper premiums. But there’s a catch — the costs for health care are out of pocket until the high deductible is met.

A new survey from the Commonwealth Fund found that three in five low-income adults and about half of adults with moderate incomes believe their deductibles are difficult or impossible to afford.

Is health insurance the new paternalism in health care? Paternalism is defined by the Oxford dictionary as, “The policy or practice on the part of the people in positions of authority of restricting the freedom and responsibilities of those subordinate to them.”

Let’s take a look. Health insurers dictate what care can be delivered to patients and which prescribed medications patients can take. They have narrowed choices of medical providers on their plans, forcing many patients to leave their doctors and hospitals of choice. Insurers have increased costs for health plans by as much as 20 percent and now offer more high deductible plans, causing people to delay or refuse medical treatment because they cannot afford out of pocket costs (self-rationing).

Seems to me that health insurers are in the driver’s seat.

Martine Ehrenclou is a patient advocate.  She is the author of Critical Conditions: The Essential Hospital Guide to Get Your Loved One Out Alive and The Take-Charge Patient.


View 33 Comments >

Most Popular

✓ Join 150,000+ subscribers
✓ Get KevinMD's most popular stories