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.
No comments:
Post a Comment