OPINION – The other day, a colleague rang me to discuss how Obamacare had affected his healthcare. For the purposes of this commentary, I will call this individual Lee. Apparently, Lee has a chronic condition that requires that he be infused with certain drugs periodically to ensure he survives. Lee's health plan offering was no longer available. The only offering he could find was one that had a "narrow network," which neither included the physician he had seen for years, nor the hospital he had gone to. Oh yes, and he added that all the drugs he needed were not covered. Lee was concerned that the cost of the drugs might be over a hundred thousand dollars a year.
I have no idea what Lee might be paying for health insurance, but let us assume it's $20,000 a year. Lee was concerned about the narrow network and the additional out-of-pocket costs that he would incur. Fortunately, he can afford to pay these out-of-pocket costs. I could not help but think about a person who could not afford the $20,000 for health insurance before Obamacare, but now may have some form of coverage. This individual presumably will receive some subsidies, but if he only has a narrow network offering, he might find himself in a similar situation as Lee, but without the wherewithal to pay the out-of-pocket costs.
When I was at the American Medical Informatics Association meetings in Washington, D.C., in November, I read in the local paper how Bowie State College, a traditionally small black college in Maryland, was discontinuing its health insurance offering due to Obamacare because the semester cost of health insurance was going up from $50 to $600. I'm not sure what kind of plan it was, but I would think some form of health insurance would be better than none.
I found out the other day that an adjunct professor friend of mine learned that she did not qualify for the offerings on the exchange in her state, and she should apply for Medicaid. Last time, however, she was told that she was not eligible for Medicaid.
Then, of course, there are a number of stories of individuals who do have some form of health insurance now under Obamacare, and for the first time ever. Curiously, I received an e-mail from HHS.gov on Sunday, March 16, 2013, and it mentioned a 29-year old single mom who was able to enroll in a Silver Plan for $18 per month. Unfortunately, there was no mention of the network. Although these stories do not usually rise to the same level as the other stories might, they are all interesting. Newly insured individuals are trying to access the healthcare system, other than through free clinics and emergency departments. These developments should be considered good.
I cannot help but think about the uncertainty of all of this for people and their families. I did read the legislation that created Obamacare. In fact, I read parts of it a number of times. Many of these situations could be anticipated and others perhaps less so. Too bad all too few members of Congress read it or had their staffs study it for its import. Be that as it may, it's now time to figure out how to fix Obamacare and its anticipated and unanticipated consequences. Neither repeal nor the use of the pen and phone will fix it. Our elected representatives need to sit down and determine what it should have looked like in the first place, and address the issues in getting there. This is what many people trying to solve problems do—they consider what the best alternative or solution might be and then work to get there. The health of our population is at risk, and the uncertainty is disturbing for many. What about a call to action?
Paul R. DeMuro JD, CPA, MBA, MBI, Schwabe, Williamson & Wyatt, PC, National Library of Medicine, Post-Doctoral Fellow in the Ph.D. Program with Oregon Health & Science University.
Mr. DeMuro is uninformed, and he has plenty of company. The problems he cites are old ones, preceeding the Affordable Care Act by decades. Limited networks, prior authorizations, drug formularies, etc. have been around for as long as there has been health insurance. Health insurance has always been a "buyer beware" market, rampant with "gotcha's" of all shapes and sizes.
The fact is that under the ACA, far greater uniformity exists between heath benefit plans than ever before, since standard benefits are required in order for health plans to be qualified. They must contain all 10 categories of essential health benefits, and they must have the same actuarial values and out of pocket expenses for bronze, silver or gold plans. In Oregon, this is a matter of state law, federal and state exchange oversight and regulated by the insurance division. That does not mean that there are no "gotcha's", and network limitations, absence or limitations on out of network benefits, restrictions or large coinsurance requirements on pharmaceuticals (especially "specialty" infused drugs) are rampant. So buyers still need to pay close attention.
But the author is misplacing his blame on Obamacare. It seems very popular to blame anything and everything on Obama, especially if you are not really interested in discerning the facts. I guess I expected more from a lawyer......shame on me.
For as much education and designations Mr. Demuro holds, there is a profound amount of misinformation and ignorance presented in his opinion piece. Here's a few:
1. He wanted us to presume his friend has a $20,000 premium. Why presume such a high premium? In Oregon, The Moda Be Savvy bronze plan is $289 per month for a 55 year old, closer to $3000 per year. It offers a network that covers nearly every hospital in Oregon, including OHSU, and it caps the out of pocket for a year to $6350 (in network). Keep in mind this is the LEANEST plan Oregon offers.
2. His friend would have a choice of 9 companies offering 1000 plans through Cover Oregon if he didn't like his current plans 'narrow network'. Some plans once you hit that $6350 (in network), 100% of approved prescriptions are covered in full. Is every drug covered automatically? Of course not, nor should it. Forcing approval of every overpriced name brand drug would crush the system.
Another one of the new Oregon Co-op's, Health Republic covered another one of my clients for her designer drug, and the plan has a $1000 maximum out of pocket--deductible, copays, RX--$1000 total out of pocket.
As an Oregon Insurance broker 15 years here in Oregon, I can attest that we have an amazing selection of companies, plans, and broad doctor networks available to most needs folks have. Let's fix the system we have. It it does need replacing, let's not get there by putting out articles like this one to exagerate Oregon's insurance offerings.
--Dan Neils, Agape Insurance
I am most pleased with the dialogue which has emanted from my Commentary. Those who have commented have provided quite valuable information. I know with its national scope, the Lund Report seeks to provide its readers with the benefit of many points of view. I and Diane encourage continued constructive dialogue.
Unfortunately, I can only amplify to a limited extent my remarks because of attorney client privilege limitations. Lee does not live in Oregon. Lee contacted me a few weeks ago, not years ago. I am advised that premiums for my group sponsored health plan in Oregon are over $20,000 this year for my family. The premium is a combination of what I pay and the company pays. It is a very good plan. I am informed that the premiums went up about 15% from last year. Lee lives in a higher cost state than Oregon.
Late last week, I had the privilege of being in meetings back East with a number of healthcare benefit leaders across the US, including a number of attorneys, accountants and others in the Obama Administration. When I raised some of the consideration from my Commentary, a few noted that there might be a need for some fixes, as one of the commenters mentioned. I think many are dealing with semantics in a sense. I continue to believe that all should have access to affordable healthcare. Unfortunately, a number of individuals who have contacted me do not believe they have such access. I continue to believe that the solution is neither the wholesale repeal of all of the provisions of Obamacare, nor tinkering with it around the edges. We need a workable solution to our healthcare situation, and we need to constructively develop a solution, and then work toward getting there.