As the Obamacare machine continues to grind forward, many patients have re-enrolled in a second year of coverage. While most have not had to use their insurance (the young and healthy crowd), others have found their newly minted coverage to be far less than promised. High deductibles, and up front out of pocket expenses, forced many covered by the exchanges to avoid seeking regular preventative care. Prevention was one of the tenets of the ACA. Many have found choices limited and have been forced into health care systems that are not their first choice.
Now, as the second year of enrollment (and re-enrollment) has concluded, many of us are concerned about the likelihood of rate hikes and changes in coverage. The Obama administration continues to tout the fact that enrollment numbers remain high and that there have been no substantial increases in premiums.
However, this is not necessarily the case. Many exchange insurers have cleverly disguised rate hikes through changes in other aspects of the plans. While some advertise that there are absolutely no significant premium increases, customers who shopped carefully on the exchange site were able to find higher prices for emergency room visits, and higher charges for nongeneric drugs. For some plans this means that rather than pay a $250 copay for an emergency room visit, the customer must pay up to the yearly deductible for the same ER visit before the copay rules go into effect. For many, this may be a non-starter. ER visits can be very expensive and can amount to thousands of dollars in just a few hours. Many patients will find themselves having to pay a 3 to 6 thousand dollar deductible early in the insured year before any of the benefits begin to contribute to reduce individual out of pocket costs. In some plans, the copayment for a routine physician visit will go down by an average of $20 and many generic drugs will be covered for free. However, specialty visit co-pays will increase, and the prices for specialty medications will increase by 40 to 50 percent.
In an effort to promote re-enrollment in 2015, the government implemented an automatic re-enrollment system. However, this has left many patients with increasing out of pocket costs because multiple changes have been made — such as those described above. Many patients were unaware of the need to shop around for re-enrollment and are now increasingly unhappy with their plans.
Ultimately, the ACA and its supporters in Washington have placed statistics and politics ahead of the patient. While the delivery of quality care to the patients who need it should be the goal, it appears that politics remains the top priority. Increasing out of pocket costs and higher deductibles — many requiring payment in the first half of the year — are having the opposite effect. One of the central tenets of the ACA is to focus on prevention through promoting regular access to primary care physicians for prevention of chronic disease and its complications. However, rather than promoting and environment where patients are engaged and actively seek preventative care, many are using the insurance simply as a disaster plan simply due to the overwhelming costs. While out of pocket limits and guaranteed care consume the health care reform talking points of the Obama administration, the reality is that the way in which the ACA is structured and implemented has actually increased personal financial burden for many.
What can patients do?
Unfortunately, much of the burden of navigating the new health care landscape falls to the patient. The law itself remains a moving target—with changes certain on the horizon. We must remember that insurers are for-profit entities and will ultimately find a way to make a profit — often at the taxpayer and patient expense. While many have been encouraged by the Obama administration to continue to offer affordable premiums, most have found other ways to improve their revenue streams. Whether it is through juggling co-payments and charges, shifting cost, denying procedure approval or limiting choice, all of these changes will negatively impact patients. As a health care provider, my job is to educate patients about behaviors that may improve their overall health. Now with the implementation of the Affordable Care Act, this responsibility now extends to helping my patients manage their insurance choices. While this is not necessarily a traditional role of a physician, it is important that we make sure that our patients continue to have access to the care they need — without incurring a life altering expense.
There are a few things that I think that patients can do to actively advocate for themselves and others:
1. Stay informed. Make sure that you ask questions of your insurer: Are their changes to my coverage? How are out of pocket expenses handled? Can I see my doctor and my specialist when I want or need to without incurring a penalty or increased cost?
2. Shop around. Just because you have had coverage with a particular company in the past does not mean that you have to remain locked in with them. Make sure you explore all of the options that are available to you through the exchanges. Carefully question insurance company representatives so that you completely understand policies before you agree to a contract
3. Demand transparency. If you are unable to get a clear answer from an insurer about costs and coverage before you sign up, it is very unlikely that you will get a clear answer once you are a customer. Once you are a customer, make sure that you have a clear idea of the costs involved prior to scheduling a procedure or test. A recent survey sponsored by the Robert Wood Johnson Foundation found that nearly 56 percent of Americans get out of pocket cost information before accessing health care services.
As with most things that have occurred with the Affordable Care Act, it is the patient who ultimately suffers. Insurers continue to profit, as do drug makers and hospital systems and administrators. Physicians have seen reimbursement cut to levels that have forced integration with large hospital systems. Most tragically, however, patients tend to be caught in the middle and have seen their health care suffer. Surveys indicate that patients are now inquiring as to cost prior to office visits, tests and procedures. Many find that they must put off necessary preventative activities and even more opt not to have needed tests and therapeutic procedures due to cost. It is clear that the ACA has missed its mark.
While insuring large numbers of Americans is a noble goal, this insurance must also provide value rather than meaningless statistics to be utilized at a White House press briefing. As my research mentors at Duke University taught me during my training: With any data analysis, it remains that garbage will equal garbage out. We must find a better way to provide affordable care to our patients. For now, insurers, hospital systems, and politicians are using patients as nothing more than a profit center. As re-enrollment continues through this year and the next, we must make sure that our patients are armed with the old adage: buyer beware.