WHEN Karen Pineman of Manhattan received notice that her longtime health insurance policy didn’t comply with the Affordable Care Act’s requirements, she gamely set about shopping for a new policy through the public marketplace. After all, she’d supported President Obama and the act as a matter of principle.
Ms. Pineman, who is self-employed, accepted that she’d have to pay higher premiums for a plan with a narrower provider network and no out-of-network coverage. She accepted that she’d have to pay out of pocket to see her primary care physician, who didn’t participate. She even accepted having co-pays of nearly $1,800 to have a cast put on her ankle in an emergency room after she broke it while playing tennis.
But her frustration bubbled over when she tried to arrange a follow-up visit with an orthopedist in her Empire Blue Cross/Blue Shield network: The nearest doctor available who treated ankle problems was in Stamford, Conn. When she called to protest, her insurer said that Stamford was 14 miles from her home and 15 was considered a reasonable travel distance. “It was ridiculous — didn’t they notice it was in another state?” said Ms. Pineman, 46, who was on crutches.
She instead paid $350 to see a nearby orthopedist and bought a boot on Amazon as he suggested. She has since forked over hundreds of dollars more for a physical therapist that insurance didn’t cover, even though that provider was in-network.
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.
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.
Alison Chavez, 36, who is self-employed, signed up for a marketplace plan in October 2013 that she hoped would be an improvement on her previous plan. She had recently been given a diagnosis of breast cancer and was just beginning therapy, so she was careful to choose a policy on the Covered California marketplace that included her physicians.
But in March, while in the middle of treatment, she was notified that several of her doctors and the hospital were leaving the plan’s network. She was forced to postpone a surgery as she scrambled to buy a new commercial policy that included her doctors. “I’ve been through hell and back, but I came out alive and kicking (just broke),” she wrote in an email.
Dr. Alexis Gersten, a dentist in East Quogue, N.Y., switched her family and 11 employees to a new Blue Cross/Blue Shield plan for 2014, after a previous small-business group plan was canceled. She bought the plan through a broker, and says she was unaware that it was an Affordable Care Act plan. When her son needed an ear, nose and throat specialist, the nearest was in Albany, five hours away. Though her cardiologist was on the network list, he said he did not take the plan. She ended up driving an hour to see a new one. A dispute with the insurer about how to count deductibles left her with a $457 pediatrician’s bill. This year she has chosen a new policy.
“People may have a checklist when they buy insurance: First, premiums, then the deductible — and those are pretty easy to understand because they’re set dollar amounts,” said Lynn Quincy, associate director of health reform policy at Consumers Union. But new policies demand different and more difficult kinds of calculations, she said: “The terms are unfamiliar, and figuring out networks is especially murky.”
Compounding the problem is the lack of basic information to shop effectively. When Andrea Greenberg, a New York lawyer, called the help line of Health Republic to clarify the difference between two plans, she found herself speaking to someone reading off a script in the Philippines. “I was really outraged,” she said. “This is an important decision with potentially dire consequences. It’s not like you’re choosing a sweater.”
Likewise, it took many phone calls for Aviva Starkman Williams, a California computer engineer with insurance through her employer, to determine whether the pediatrician doing her son’s 2-year-old checkup was in-network for 2015. Only three of the pediatricians in her doctor’s six-person group were listed in her plan’s online directory, and since her deductible had tripled from the previous year’s, she wanted to limit her out-of-pocket payments.
The practice’s office manager couldn’t tell her for sure. The insurer’s representative said he didn’t know because doctors came in and out of network all the time, likening the situation to players’ switching teams in the National Basketball Association. “If you don’t have updated information, who does?” she asked. “Isn’t it your job to know?”
Ms. Quincy said regulators needed to do a much better job setting requirements and policing plan practices and offerings, particularly provider networks. Few states have clear standards and many rely on consumer complaints to ferret out problems.
Last month, the California insurance commissioner, Dave Jones, announced new emergency regulations concerning networks, noting: “Health insurers’ medical provider directories have been inaccurate, misleading consumers into signing up with a health insurer for access to a doctor, specialist or hospital, only to learn that these medical providers are not actually a part of the health insurer’s network.”
But for now, patients are most often left to fend for themselves. When Amy Moses, a tech entrepreneur in New York City, went online to select a plan, she paid a relatively pricey $650 per month for a United Healthcare plan to make sure her network included a longtime physician. One month into the year, the doctor’s practice was bought by a hospital, which then dropped the plan, so her doctor did as well. (A year later the doctor was still listed in the network directory.)
She discovered the change only when she contacted the physician for a referral for an urgent outpatient procedure costing thousands of dollars that had been recommended by an in-network surgeon. (Both the referring doctor and the surgeon had to be in-network for coverage.) “I literally had three days to find a new in-network internist and score an appointment to get a referral, or cancel my procedure,” she said. “I was stuck in insurance purgatory.”
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