Even with ACA, ‘insured’ doesn’t necessarily mean ‘accessible’

water-wordle-transparencyElisabeth Rosenthal’s latest piece on the craziness of our health care pricing looks at affordability of health care for people covered by the Affordable Care Act.

For people purchasing insurance, premiums are only part of the cost, although they are what many consumers focus on when they choose a plan. There are also deductibles, co-pays, and different rules for in-network and out-of-network care. For people covered by ACA exchange plans, costs can mount, big time, and it can be very confusing for patients to figure out what they are being or will be charged.

She writes:

“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.”

For some patients:

”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.”

Many people are paying more for health care than they were before (although you can argue about how much of that is because of the Affordable Care Act, or whether price increases might be even worse without it.) And people are now getting preventive care for free – although that’s underreported and misunderstood.

The opaqueness of networks and charges is by no means unique to the ACA. I’m a pretty sophisticated health care consumer, and I’ve had the same health care plan through my job for 3-1/2 years. But I’ll be darned if I can explain to you why, when I had a tiny bone fracture in my hand, I paid something like $67.50 for an in-network orthopedic specialist with part of the fee going to the deductible but, when my eyeball had an unfortunate (though minor) encounter with a branch that did not want to be stuffed into those big brown gardening waste bags, I paid $50 with nothing toward the deductible, to see an eye specialist (not for glasses, this was covered under medical, not vision). Or why, because I see one doctor once a year out of network, insurance covered half of it one year, and not a penny toward pretty much identical medical services the next.

These were minor in-network outpatient expenses; I can pay the bills. But even with everything I know about health care and insurance, I am not at all confident I could avoid unexpected expenses if I or a family member had a serious health problem, even if I tried to stay in network (and it’s not always possible to stick to in-network doctors even if you are at an in-network hospital or emergency room, as Rosenthal’s series has explained with such shocking clarity.)

As Rosenthal notes, Congress is not exactly in the mood to come up with simple bipartisan fixes to the ACA. But it’s not all Congress’s problem, or even the Department of Health and Human Services (although HHS does have some regulatory power over network adequacy in the ACA and it’s looking at networks).

Most of the responsibility for insurance regulation lies with the states and, as Rosenthal says, California insurance commissioner Dave Jones, who has been a more aggressive state regulator than most, has already announced new emergency regulations. A few state legislators have also started looking at aspects of the narrow networks and the National Association of Insurance Commissioners is, too.

You can track what your state legislature, and your state insurance commissioner is or is not doing – and why. Consumer and patient advocacy groups can also be useful here. A few suits have been filed; are more to come?

The issue goes beyond the actual adequacy of the network providers – whether the network has enough health care providers, covering the necessary range of specialties and services, and whether they are close-enough reach to be practical.

Transparency is key:

  • How easy is it to find out who is and who is not in the network?
  • Should providers have to inform you if they leave a network during the plan year?
  • Can you find out, accurately, what drugs are covered, and how much you’d have to pay?
  • What happens if you are admitted to an in-network hospital, but, without your knowledge or control, some of the providers involved in your care are out of network?
  • What happens if you have a time-sensitive condition and can’t get an in-network provider – will any states address that effectively?

It would be interesting to see – and I haven’t yet – if transparency becomes a marketing tool, if we start seeing insurers boasting that they are more clear about their providers or formularies lists than their competitors. Maybe local news reports comparing accuracy of provider directories and the like would add to the pressure.

Chad Terhune of the Los Angeles Times has done very good work on the directory accuracy issue in stories like this. Trudy Lieberman also has advice on how to cover the network issue in CJR.


The National Conference of State Legislatures is holding a webinar on “Hot Issues in Health” tomorrow, Feb. 20, that promises to touch on how states are improving their return on investment in Medicaid, what’s new with insurance and exchanges, telehealth, childhood immunization policies in light of the measles outbreak, blockbuster prescription drugs and what they mean for states, health cost containment trends and emerging marijuana and e-cigarette issues. Might be a good time to get in touch with your legislators. It appears that “credentialed” media can access the webinar for free, after going through a registration process.

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