Thursday, February 27, 2014

What the Affordable Care Act Means For Our Family

The past few months have been eye-opening and discouraging. I felt relief when the Affordable Care Act passed, and spent the last four years championing its cause among my friends, family, and coworkers.

I've come to realize, however, that access to health insurance doesn't at all mean access to healthcare. The health insurance companies met the ACA's requirements for accepting everyone, regardless of pre-existing conditions, covering basic wellness tests, and providing free contraception. But we can't legislate a shark into a guppy. Health insurance companies are for-profit organizations who will bend to the letter of the law, without changing the foundation of their business model: profits come from not paying for healthcare.

For most of the past 10 years, I haven't had access to traditional, employer-sponsored health insurance. This has been for many reasons, of which unemployment was only a brief and temporary cause. I've been a dance teacher, a grad student, spent several years with a contemporary dance company, student taught, and currently work part-time in an office. My husband is a contract employee at a sports station, picking up production truck work and umpire gigs on the weekends. We have two kids, ages 2 and 4, one of them has a pre-existing condition that requires regular medication and occasional trips to the ER.

We don't qualify for employer-sponsored health insurance, because we each work less than 40 hours a week. (Once the Affordable Care Act changed the requirement to 30 hours per week to qualify for employer-sponsored health insurance, subsequently delayed to 2015, my husband's job capped his hours even lower to prevent reaching the new threshold.) We also don't qualify for Medicaid, comprehensive healthcare for the very poor.

Before healthcare reform was even being discussed, we looked into independent plans through a variety of health insurance providers, and the cost-benefit ratio was abominable. It came as low as $400 a month for a catastrophic plan with absurd co-pays and co-insurance, an unreachable deductible, no coverage for maternity, nor any provision for pre-existing conditions. Basically, a guarantee for the health insurance provider that we would never use their health insurance.

We joined a healthcare co-op and started a savings account instead.

Interestingly, before the Affordable Care Act, not a single independent health insurance plan in my area covered maternity care. Talk about wiping out the middle class. To anyone between Medicaid and the gold standard of employer-sponsored health insurance: do not have children!

So I started out optimistic about Obamacare, because it would meet a very real need for my family. I'm still hopeful it can inaugurate comprehensive healthcare for all.

I signed up on healthcare.gov to receive updates, before it was even launched. All of the anticipation and momentum leading to open enrollment left many, ourselves included, frustrated in the ensuing crash, followed by weeks without access, and months without the ability to update your information. (We're still in that phase of the roll-out, unable to adjust family income or size.)

There's this encouraging update, once you complete your application, before plan estimates are posted:


I'm so glad these are finally considered basic health care. (Or are they?)

According to the estimates that came up on the website, my family of 4 qualifies for health insurance plans ranging in price from $515 - $1308. These prices are not as offensive to me as the somewhat lower price quotes from health insurance companies last year, because these premiums include preventive care, prescriptions, doctor visits, maternity and newborn care, and hospitalization.

Based on the healthcare.gov website, here's the breakdown of income qualifications for government subsidies:
  • 1 Person: $11,490 - $45,960
  • 2 People: $15,510 - $62,040
  • 3 People: $19,530 - $78,120
  • 4 People: $23,550 - $94,200
  • 5 People: $27,570 - $110,280
  • 6 People: $31,590 - $126,360
  • 7 People: $35,610 - $142,440
  • 8 People: $39,630 - $158,520
If you make under the minimum income level for each family size, you may qualify for coverage under Medicaid.

Finally our health insurance plan options started coming up on the screen. And I realized nothing had changed, except healthcare via health insurance was now more inaccessible than ever.

With a government subsidy, we would pay $358 each month for the lowest plan. At this level, the health insurance company pays for nothing -- sick visits, prescriptions, specialists, Emergency Room, surgeries -- until we meet an annual deductible of $12,700. For a middle-class family of four, we will be out-of-pocket $16,996 in one calendar year (including premiums), and the government will be out-of-pocket $2,016 in additional subsidies paid directly to the insurance company on our behalf, before any kind of health insurance assistance would begin. After this $19,012 up front, we would be responsible for 20% of all medical bills, until the calendar year turns over, at which point we'd need to meet $19,012 again before insurance began to help.

I know there are many levels of plan available on the healthcare exchange, and the sheer number of plans available would make you think it's simply a treasure hunt for the right plan. But, pardon the expression, a box of shit giftwrapped 200 different ways is still a box of shit. After analyzing all of our plan options on the new public health insurance exchange, we came to the same conclusion on every single plan: we would be out an ungodly amount of money before any kind of actual health care coverage begins.

I shouldn't have been surprised. The goal of the Affordable Care Act wasn't to create a non-profit healthcare system. Yet health insurance companies have turned our national healthcare campaign into a profit-generating scheme, collecting our tax dollars, in the form of government subsidies, while ensuring those who most need healthcare are no closer to receiving it.

One might say we don't have a reasonable understanding of medical costs, that there's a reason health insurance companies need middle-class consumers to be out-of-pocket $19,012 a year before coverage begins. But we've been self-pay healthcare consumers for two years now, with wellness visits, sick visit, several ER trips, and even surgery. Last year our out-of-pocket healthcare expenses totaled $7,495.30, which included two trips to the ER, one by ambulance, an eye infection, a kidney stone, craniosynostosis follow-up with a specialist, asthma maintenance, many prescriptions, and wellness visits for our kids. We spent an additional $3,810 in premiums toward a non-profit healthcare co-op, which has been the affordable solution for our family's medical needs.

Through the self-pay experience, supplemented by sharing costs through our healthcare co-op, we've realized the disparity between real healthcare costs and healthcare costs through a health insurance company.

I'm still compiling medical bills for our son's recent surgery to remove his adenoids. This included several pediatrician visits, specialist visits, pre-op scopes, anesthesia, and the use of a for-profit day-patient surgery center. Our pediatrician was thrilled that we were self-pay, when he diagnosed a problem with our son's breathing and referred him to a specialist. We could go directly to the best pediatric ENT in Dallas, no need to check networks. When we went to the specialist, he was also thrilled that we were self-pay. We could immediately take the course of action needed, without having to jump through bureaucratic hoops with the insurance company. There was no need for expensive additional tests at a sleep center, weeks of an expensive prescription regimen, or the added cost of pre-surgery ER trips to manage his breathing while the insurance company processed approval paperwork. When we paid the self-pay rate at the pediatric specialty surgery center (no financial aid included), the administrator told us we were actually paying less out-of-pocket than several patients who had health insurance, because their deductibles were so high.

Some might say I'm missing the entire point of health insurance, that it exists only for the very extreme and expensive needs of cancer, heart transplants, HIV, stroke, and the like. I think this would be a wonderful application of health insurance. I wouldn't mind having health insurance only for the most catastrophic health events. But we can't afford to pay 25% of our income toward this vague possible future, while continuing to pay 100% out-of-pocket for current, less serious healthcare needs. A $500 monthly premium toward a healthcare plan that we only use in the most extreme circumstances is just not feasible for anyone in the middle class.

At first, I thought it was just my family experiencing problems with healthcare access, but as we share our healthcare experiences, more and more people are coming to me with their stories, much more difficult than our own. Teachers are spending a quarter of their income, just on health insurance premiums, before any money is spent on their families' healthcare needs. Employers are opting for high-deductible plans, which keep healthcare inaccessible, even to those with health insurance. Companies are hiring more part-timers and cutting hours to avoid obligations to provide health insurance.

I'd like to propose that we work around health insurance companies in our national endeavor to ensure healthcare is as accessible to all as roads and education. Why do we even have a for-profit middleman in healthcare? It's awesome that the government wants to help my family with a $168 subsidy each month, but instead of sinking it into the murky profits of health insurance premiums, deposit it in a health savings account in our name. Or calculate it into our annual tax return. (Perhaps to cover the penalty tax of not carrying health insurance? Though, for the record, our not-for-profit healthcare co-op fulfills the individual mandate of the Affordable Care Act that requires everyone to carry coverage.)

Our country's approach to health care is broken. The Affordable Care Act does not solve all of the problems, nor could it anticipate all of the problems. But it's something, and I'm grateful that someone's doing something. And I hope it can be restored, exchanged, or upgraded into a system that's sustainable and accessible for everyone.

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