Obamacare... Next Steps

Obamacare transformed the landscape of the health insurance market for individuals. It also set standards for required/mandated services that all health plans (individual and group) must cover. The demand for full-coverage preventive care services is very women-centric and, to be honest, needs to be updated to include additional coverage for men's health services. In addition, the Unites States Preventive Services Task Force, the agency that sets the parameters for the preventive services that are covered, needs to consider additional variables. For example, for screening colonoscopies, the age parameters are set to allow beginning at age 50. However, African Americans are at a higher risk, and should be allowed to begin screening at age 45.

But simply making insurance more available to individuals is not enough. First and foremost, Obamacare is slang for the Affordable Care Act. Yet, for many, the individual plans are not affordable at all. A single person living in NYC, making $50,000 a year, does not qualify for a subsidy. He or she has to absorb the full cost of their health plan.

Looking at one of the bigger insurance carriers offering insurance in the NYC area (Empire BlueCross BlueShield), the cheapest plan offered has a monthly price tag of $435.20 per month, a deductible of $5,850.00 and an out-of-pocket maximum of $6,850.00 per year. What this means is that if you are single and need to actually use your insurance, you can expect to pay up to $12,072.40 for health services each year, with NO financial assistance. Over 20% of your gross salary. And if you're single in NYC, you can expect to lose at least 28% of your paycheck to taxes.

So... your $50,000 income feels more like $36,000, which means that $12,000 for insurance and healthcare services is actually more like 1/3 of your income. And you haven't paid a penny in rent, or utilities, or food or clothing or your Metrocard.

On top of that, Empire has many different network options, however all of their ACA plans are linked exclusively to their Pathways network. Pathways includes a fraction of the number of providers that their more robust PPO networks offer. The reimbursement to Pathways providers is so low that the majority of doctors and hospitals will not join. So I can't help but wonder why a plan that pays its providers so little AND has such a high deductible is also so ridiculously overpriced?

It's not just Empire though. Most insurance carriers have various network options for providers. Joining one network does not mean that the provider is in-network for all of their products. And for all carriers, those who are purchasing insurance off of the exchange (Obamacare plans), are stuck with very narrow networks of providers. And to make things even more difficult for consumers, ALL marketplace plans are either HMO plans or EPO plans, which means that there are NO out-of-network benefits.

And for those of us who are lucky enough to have employer-provided health insurance, we're not safe from these issues either. Insurance has always been divided into 3 groups: large group (50+), small group (2-50) and individual. Large groups are being redefined as groups of 100 enrollees or more. Small group is now considered 2-100 enrollees. Many of the small group plans offered are very similar to the individual plans, meaning no out-of-network benefits and the narrow networks.

It is my belief that as long as health insurance is part of the for-profit industry, HEALTH is not a major consideration, and we the consumers will always be on the losing end. Profits will continue to be the driving force and people will continue to be a second thought. There needs to be sweeping changes to the healthcare industry as a whole. Not just to insurance companies, but to pharmaceutical companies and to healthcare providers as well. Each carrier has ONE network. Either a doctor/hospital/provider is in or out. And reimbursement should be based on Medicare/Medicaid rates. It is ridiculous for the federal government to assign a fiduciary value to a service, yet allow providers to bill 20, 30 or more times that value to commercial insurers and to private pay patients. And we as consumers need to be more invested and involved in our WELLNESS rather than seeking out care only when we're sick. There has to be a concerted effort on all fronts, but we can fix this healthcare industry crisis.