Thursday, September 1, 2016

Reflections on the Affordable Care Act- A Dispatch From a Member of the New "Underinsured"

While Bernie Sanders was running for Presidential office, I was often struck by his frequent calls to reform the health insurance industry to benefit the millions of Americans who are “underinsured.” Rather than draw a rigid dividing line between those who are covered by health insurance providers and those who are not, he recognized a large and growing gray area of Americans who possess some form of health coverage but who find their benefits inadequate during times of illness when they need them most. The new masses of the underinsured are an unfortunate by-product of the new insurance programs made possible by the Affordable Care Act (“Obamacare”).  The ACA admittedly reduced the famous statistic of “47 million” uninsured Americans that President Obama frequently referenced during his bid for office in 2008, but also generated some 31 million who are now “underinsured.” What does it mean to be underinsured? How does it play out in the lives of many who have purchased some form of Obamacare only to face high health care costs which bear a striking resemblance to holding no insurance at all?

I’m intimately acquainted with the lived experience of the underinsured, as I’m one of them. A 27-year-old Ph.D. student living on a modest university stipend, I purchased two forms of Obamacare in the last two years given that my annual income is too high to qualify for Medicaid eligibility in my state and too low to afford the insurance plan available through my university. I first opted to enroll with an ACA participating provider in January, 2015. My first insurance plan was with what was at the time the largest Obamacare-created, nonprofit insurance cooperative on my state’s market. I enrolled in an individual “Catastrophic Plan” – meaning that my insurance had a deductible of close to $7,000 and covered almost no services with the exception of a handful of a few preventive measures, including an annual physical. Over the course of the eleven months I spent enrolled in this plan, I watched as it gradually pulled out of several of New York’s top hospitals and finally, in November of 2015, was quite suddenly liquidated due to financial insolvency. I was informed of my insurance company’s collapse in late September of that year. Left without coverage for December of 2015, I was liable to be taxed under Obamacare’s penalty for the uninsured. The irony of the situation is lost, I’m sure, on no one.

In December 2015 I found myself in the same situation as the year before – unable to afford the insurance option available through my university, and ineligible for Medicaid. So I returned to my state’s marketplace once again in search of a new provider. Again I enrolled in an individual “Catastrophic Plan,” this time with a private insurer that offers some of its plans through the Obamacare system. This is the insurance plan which I continue to hold today. One may ask why I insist on purchasing “Catastrophic Plans,” which, as their name suggests, are really only useful for a rainy day – or, more literally, if the insurance holder were to find him or herself in a medical emergency. Accordingly, under this plan my deductible cost is over $6,800. In fairness to my decision, however, the next available option for an individual plan – one with the same deductible – costs nearly $400 a month. That number comprises a fifth of my monthly salary. I can’t afford it. And generally speaking I’m a healthy person, so it seemed unnecessary to spring for a plan with more coverage, given that I have to choose.
I had no complaints about my insurance provider until this past summer, when I became sick with what turned out to be a potentially serious but overwhelmingly treatable illness – I had a heartburn condition that was on a steady march toward forming a stomach ulcer. Initially, burning stomach pain and a decreased appetite sent me to my insurer’s website in search of a gastroenterologist. Here I found myself violating at least two of the unspoken norms of my insurance package. I was in need of a doctor, and not just any doctor, but a specialist. I almost never saw the excellent doctor that ended up treating me as my insurance company, despite having listed her on its website, informed me that she was no longer an in-network doctor. Like my previous provider, complaining of financial losses, this year alone my insurance provider pulled out of some forty hospitals, so this may account for the confusion. Nevertheless, after more hours invested in searching for a new, in-network doctor on my insurance website, the staff at the office called to inform me that they double-checked and my doctor turned out to be in-network. A day of hassle but at least I had an appointment.

After my visit, my doctor prescribed a relatively new drug to treat acid reflux. It’s also been shown to be one of the most effective drugs for reflux on the market. Unfortunately, I can’t corroborate my own experience with available studies as I never took the medication. Shortly after my doctor ordered it to my pharmacy, I received a phone call with a voice message informing me that my prescription was delayed because the drug needed to be “authenticated.” It turns out that when insurers find a drug too expensive, they prevent pharmacists from filling a prescription for it until the prescribing doctor calls and argues for the medical necessity of the drug in question. The medication I needed, with insurance, was going to cost $300. There is no generic option available, so instead my doctor prescribed a much more affordable generic drug that belonged, importantly, to the same family of the drug originally prescribed but was not simply a generic version of that same drug. The devil is in the details here because the drug I ultimately took did not work well. When I called up my gastroenterologist informing her that upon taking the medication, my heartburn not only did not subside but seemed to have gotten worse, I heard her faintly suggest to herself that the original drug would have likely worked better.

My doctor went on to explain that because of my continued pain, she would like to order an upper endoscopy. A somewhat invasive but generally routine exam, an endoscopy would allow my doctor to ensure that my heartburn issue did not have a more serious cause. I called up my insurance provider to receive a cost estimate for the exam. I knew it was uncovered, but I was feeling hopeful (otherwise known as “desperate”) that night, so I asked anyway. I was surprised to hear the voice on the other end cheerfully explain to me that the test was covered – but not in full, of course. I was guaranteed to not have to pay any more than what the medical office charged, and members belonging to my plan paid between $300 and $1200 for the exam. I was assured that the $1200 figure was uncommon, and mainly charged to people during hospital stays. To this day I’m not sure how useful it is for an insurer to provide a cost estimate that encompasses such a broad range of prices, but many providers under Obamacare pride themselves on not concealing service costs to the consumer, so they offer broad estimates on what it might cost to receive care. The difference between a thoroughly ambiguous estimate and outright concealment are, in my view, negligible. Nevertheless, I was not kept in the darkness of cost estimates for long. The next day, a staff member from my medical office called to inform me that my endoscopy exam, because I have not yet met my deductible, was going to cost $1,225. Now I was in a real bind – forego the exam and live with knowing that I may have a serious condition in need of treatment, or pay the massive bill. Thankfully, I have a credit card, which has in many ways proved to be much more useful than any of my Obamacare plans. I’m taking the not-great generic medication for my condition, which is gradually improving. The cost to see the gastroenterologist turned out to be $110 (although the cost estimate according to my insurer was $70 – but why quibble over trifles?). So, incrementally, month-by-month, I’m now paying off the $1,335 bill I earned for having a pretty bad case of heartburn. The irony returns when I think about how much worse my heartburn briefly became when subject to the stress of how difficult it was to schedule a doctor’s appointment thanks to my insurer’s mistake, combined with my insurance company blocking my medication and providing deceitful cost estimates, all to wind up with a huge bill at the end of it all.

This is what happened when I, as a member of the new underinsured, became ill. I can’t imagine what would happen if I were to be involved in a real (or “catastrophic?”) medical emergency or to need prolonged medical treatment. Very few insurance plans available through the Obamacare options in my state – with their enormous deductibles and thin coverage of medical services they do include in their plans, are prepared to accommodate a serious or long-term illness.

My story does not by any means represent the worst of what the underinsured have endured, but I think it does provide a sobering look into the everyday experience of what it means when the Obama Administration touts that 90% of Americans are currently insured thanks to the Affordable Care Act. When it comes to insurance, some plans are more equal than others.

1 comment:

Unknown said...

As a diabetic, I am constantly in a state of emergency. I can't afford the "best insurance" on the marketplace, in fact I have a hard enough time affording what I have. With that being said, I pay more for my insulin per month than I do for my mortgage. And that's after insurance pays their part. The sad part is, I don't have that awful of a plan in comparison to others I have seen on the marketplace. ACA needs to address us "grey area" people.