Want to fix Obamacare? Make Congress give a bronze plan a spin

     (AP Photo/Keith Srakocic, file)

    (AP Photo/Keith Srakocic, file)

    Combine the fright of Halloween with the expense of Christmas, and you get the scariest, most costly time of year: healthcare shopping season, presented courtesy of the Affordable Care Act. With current insurance plans ending, changing, or rising in price, millions of us approach the healthcare marketplace with extreme caution to discover how much less we’ll get in 2016 and how much more it will cost.

    This is the third year my plan has “ended.” Who knew that the Affordable Care Act would lead to insurance with the shelf life of lettuce and the price of caviar?

    Last year, when my non-marketplace plan “ended,” the insurance company offered to automatically switch me into a plan with double the premium and more than twice the deductible. How thoughtful.

    I fled to the marketplace. With the help of Carol, a navigator who helps consumers review and select healthcare, I signed up for coverage with the same insurer and really, the same plan I’d been offered. However, because I went through the marketplace and qualified for a federal tax credit, 2015’s coverage wound up costing me about the same as in 2014, with one tiny difference: Instead of a $2,500 in-network deductible, as in 2014, I have a $5,700 deductible in 2015.

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    In-network vs. out-of-network

    Which brings us to the present, arranging coverage for 2016. Once again, I received a letter stating that my plan was “ending,” and my insurer had again identified a new plan for me. And here is a surprise: The plan they recommend has a lower monthly cost. Which made me suspicious. Rightly so.

    Deep in the first page of the insurance company’s letter, I found this: The 2016 plan they propose provides no out-of-network coverage, except in an emergency. This is a feature of many 2016 plans on the healthcare network. Perhaps we’re intended to spend the premium savings on bus fare to the nearest in-network hospital or doctor. Or we can head to the nearest ER, rolling the dice that the pain, dizziness, bleeding or whatever really is an emergency. All you have to do is remain conscious long enough to think it through.

    You might not think this is important. Perhaps you don’t travel much, and you always use doctors and hospitals in your network. Yet it’s easy to wander out-of-network. For example, suppose John is in severe pain from a kidney stone and goes to an in-network ER, where he’s treated and released. Weeks later John receives a bill from an out-of-network physician who cared for him at the hospital — she may have been filling in or moonlighting, and John receives a bill for out-of-network service.

    Reasonable people might conclude that John isn’t responsible for the additional cost because he went to an affiliated facility. It should be up to the hospital, the physician, or the insurer to resolve the higher fee. Wrong. John is on the hook for the extra charge.

    So besides knowing which facilities are in your network and bringing a list of current medications, be prepared to interview care providers before they provide care. What if you’re unconscious? Here’s hoping the people resuscitating you are in-network.

    Insurers are gatekeepers

    Sooner than I wanted, I put my Affordable Care Act health plan to the test. The day after signing up for 2015 coverage, I had a diagnostic test. The results, while not earth-shattering, were potentially bone-fracturing. Not the best timing, but this is why we need health insurance, and why I’ve paid for it over a career of self-employment.

    So I went to my primary care doctor, who prescribed medicine that eventually bothered my stomach. Later, he recommended a specialist, who ordered more tests and then prescribed an alternative medication.

    The insurance company denied the request because I had not “failed” two basic medications before being prescribed the more sophisticated drug. Instead of the first choice, the specialist prescribed a brand-name variation on the generic drug I’d been unable to tolerate. A month’s supply — just four pills — cost me more than $230; I don’t know the insurer’s cost. In any case, the brand-name drug had the same effect on me as the generic.

    Soon after filling the brand-name prescription, I received a letter from the insurance company indicating that their approval of the scrip — which they essentially forced me to fill — was one-time only. The letter encouraged me to investigate more economical alternatives, and even suggested a generic — the first medicine I had tried. Gee, what a great idea.

    Subsequently, I learned that, though printed on my insurer’s letterhead, the message had probably come from a third-party firm that contracts with insurers to reduce prescription costs. Cost-containment communications are also directed toward physicians, who are as frustrated by them as their patients.

    Eventually I was approved for a different medication recommended by the specialist, and it is indeed expensive. But here’s the thing: My insurance pays only for the administration of the drug, not the drug itself, maybe due to the size of my deductible.

    Regardless of the reason, it makes me question why the insurance company controls access to a medication my physician believes I need and for which I pay. Is it because they cover the related service, the injection? Is it because an expensive drug means I might meet deductible sooner, and then the insurance company would have to pay for more than an annual check-up and flu shot?

    Walk a mile in our hospital gowns

    Let’s be clear: The Affordable Care Act is a work in progress. Care is not yet affordable: If, as Kaiser Health News reports, almost 80 percent of those purchasing healthcare through the marketplace qualify for tax credits that bring their monthly premium down to $100, their deductibles — and financial exposure if a problem arises — must be enormous.

    Though the Affordable Care Act is flawed, and those flaws have mostly gone unaddressed while Congress cynically tried to weaken and/or repeal the law, at least the United States is on the way to providing healthcare for all of its citizens.

    If I had one wish, it would be for every senator and representative, who have excellent lifetime health benefits, to spend a year in a bronze healthcare marketplace plan, doing everything the average consumer does: paying bills, wading through telephone menus; spending time on hold, making appointments, getting pre-certified, deciphering documents, receiving rejections, asking questions, worrying, and paying more bills. What they would experience as average healthcare consumers would produce a miracle cure for us all, and for everything currently ailing the Affordable Care Act.

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