How Does Health Care Matter to You?

Here are some comments in response to a survey of attitudes towards health insurance in the United States:

• I always had health insurance through my employers. Thankfully, I have worked for large practices and had my choice of PPO over HMO, also I was always able to keep my coverage between jobs thru COBRA. I am now taking care of my 85 year old mother in my home and, therefore, unable to work full-time. I hold 2 part-time jobs that allow me the flexibility I need to look after her, but no insurance coverage. I am on COBRA, but know that I will have a huge problem when the COBRA ends. There is some money to pay for my insurance if it were affordable. But my research is that no insurance company will write me an individual policy, because I have been diagnosed with Rheumatoid Arthritis. It is a mild form and in remission for now. But that doesn’t seem to matter. What about all the years of premiums paid to the insurance companies on my behalf with no claims? Where is the insurance now that I need it? I am 56 and have a lot of years before Medicare coverage. My mother’s physical health is excellent for her age and she most likely will live for many years to come, but mentally she is unable to care for herself. If I let my insurance lapse, I will get hit with a pre-existing condition on the RA when I get coverage again. So my only choice is to find a full time job for the insurance benefits only! I will have to also hire a stranger to look after my Mom while I’m at work. It will be very difficult for her. It just doesn’t make sense. I can afford insurance, but can’t get it. I will not put my Mom in a home. She was in one and stayed in bed all day for lack of attention. So, in our case, even when we can afford something for insurance the “system” won’t work for us. Also, as a side note…because her supplemental insurance premiums became so high due to her age, we switched her to a Medicare HMO. Excellent coverage, but sub-standard quality of care. It has taken us over a year to find a good physician (#3) under that plan. The first two shouldn’t even be in business, in my opinion (please remember, I have 30 years experience working for physicans). I pity the elderly that do not have a knowledgeable person to look out for them.

• I had good health care coverage for years, when for the most part I didn’t need it. Some would say I had a gold plated medical insurance plan, basically full coverage with very small co-pays.  That all ended when after 17 years with the State, I was right sized out of a job.  Fortunately at the time, my then wife had coverage.  But there still was a problem.  I lost my coverage, and even though I lost my job “through no fault of my own,” her insurance carrier kept putting up roadblocks to adding me to the policy, though the policy said spouses who lost their coverage because of a job loss that was “through no fault of my own,” they kept asking questions, asked for medical records, though there was nothing about prior conditions in the policy.  I had been in a near fatal car accident the year before, and though I was “fully” recovered, they kept asking for records from the accident.  Finally, after six months, they added me to the policy.  Fortunately I was able to keep my coverage through my HMO until my then wife’s policy finally kicked in.  And then two years ago, my then wife announced she wanted a divorce.  I was just recovering from a long term bout of pneumonia, and had gone to the doctor the day before the announcement and my internist and I had agreed that I should have a stress test.  So with a space of two weeks, I found out that I was losing my health insurance due to the impending divorce, and that I had two silent heart attacks, and would require two stints or maybe by-pass surgery.  Fortunately, I was allowed to stay on my estranged wife’s plan, only through my and my attorney’s insistence.  But then this past October, the divorce was final, and she would have not part of me staying on her plan under a separate maintenance agreement.  So off into the medical insurance wilderness I went, and only because I am a self-employed real estate appraiser, I was able to qualify for a small group plan though the Small Business Association and Blue Cross Blue Shield to the tune of nearly $500 a month.  And they don’t cover all of my nearly $1,000 a month in prescriptions due to my cardiac condition.  Again, I was fortunate, my cardiologist is providing me with samples for two of my heart medications, and three of them are now in generic form, but I still spend over $200 a month in prescriptions and co-pays.  How is anyone able to afford that?  I am barely able to, and I make decent money in my business.  But with the mortgage payment, car payment, insurance, license fees, other fees necessary for my business, I scrape it out from week to week.

• I have spent a considerable amount of time without healthcare insurance. I do have employer sponsored healthcare insurance now, but this has not always been the case.  When my wife and I were dating, she had healthcare insurance, but I did not.  The level of care we received in simple areas like preventive care was vastly different.  The minute Doctors find out you don’t have insurance, they are no longer interested in advancing healthcare to you.  I found this to be the case with several different doctors and clinics.  I also suffer from Migraine headaches.  When I went to my sister’s neurologist, his charge to her (she had health insurance) was $70.00 per visit, which her insurance paid all but $20.00 of.  My appointment, which lasted 5 minutes and did not give me any relief of the problem, cost me $156.00 which I had to pay out of pocket BEFORE going in to see the doctor.  Not only did I not receive any benefit for that, but it was clearly over twice as much as my sister paid to the same doctor for exactly the same service.

• Just three months after graduating college, after falling off of the required school insurance, but before finding full time work, my appendix gave out. I took myself to the hospital, fearing the bills. I was far more terrified of the cost than of the surgery I was about to undergo. I begged the hospital to let me out as soon as possible, given the stress of staying, knowing every hour was costing me. In the end, I was there less than 24 hours, yet had a hospital bill of over $11,000 (not including the surgeon’s bill, the anesthesiologist, etc.). This was of course far more than my annual income, and was laughable in the insanity of the billing. I had to put this on my credit card, which I had carefully kept paid off during my school years, thus blowing all the good work I had done financially while studying.

• I have been self-employed and self-insured for the past 14 years. Every year my insurance premium has increased.  So have my out of pocket expenses.  This year I went from a $2000 deductible policy to $3000 deductive and opened a health savings account with Wells Fargo.  I found that the only available fund that didn’t charge a “front-end load” of 5.25% on my $2,700, which I would be drawing down for medical expenses, was a money market fund paying a total yield of 1.1%.  That’s about what the administrative expenses cost. Okay, so I get to draw that money tax-free. That should save some money.  Except that with my higher deductible, my prescription drugs for asthma are about twice as expensive.  Not only that neither the insurance company nor pharmacies will reveal what their contracted discount is so there is no way to comparison shop for the best price.  My insurer told me that that information was confidential.  All the pharmacies, who have contracts with my insurer, told me they can’t tell me what the discounted price will be until the prescription is filled. I’ve decided to forgo one of my asthma medications because it’s just too expensive – even from Canada.  The cost of prescription drugs is beyond outrageous. As far as I’m concerned the HSA concept is a total bust.  I would have been no worse off in terms of my total yearly medical expenses to have stayed with the lower deductible and higher premium. In addition, if I want to return to my previous, lower deductible plan, I have to reapply.

• I am uninsurable. I’m a trim, fit woman in her early thirties who eats well, doesn’t smoke, takes no medicine beyond vitamins, and has no illnesses whatsoever. However, late last year, I had a miscarriage at approximately 8 weeks. Although miscarriage is very common, occurring in about 20% of all pregnancies, two insurance companies have declined me for coverage on this basis alone. In disbelief, I called the underwriting departments to check, and sadly, they both confirmed that a miscarriage without a subsequent full-term pregnancy makes me uninsurable. I am self-employed, so no group coverage is available for me. It appears that I must have a baby without the benefit of medical assistance, wait a year, and then reapply with my fingers crossed. How can this system be so broken? Who *is* insurable?

The Affordable Care Act (the ACA, or “Obamacare”) was implemented to increase the number of people in the nation with health insurance coverage—and  it did so.  The ACA set up private health insurance exchanges where individuals and families can buy private insurance, with subsidies, if they are low income.  It also authorized states to receive funds to cover nonelderly adults through their Medicaid programs;  32 states have expanded their Medicaid programs.  It prohibited most plans from excluding people with pre-existing conditions.  But it also requires private insurance offered under most plans to cover essential health benefits including maternity care, many types of preventive care, and mental health care.  Still, there is a lot of press about how choice of plans is decreasing and premiums are increasing.  Are things really worse now?   Do we really want to go back to pre-existing condition exclusions because those with them may cost more? What has changed and what still needs to be changed (but what shouldn’t change from the ACA?)

Many people like their doctor(s) and other providers; others don’t believe that whether they like the or not is important and that the most important thing is how well the doctor treats their health issues. We can’t find statistics on how many people overall are satisfied with their doctors and other providers. However, about 65% of people with Medicaid say they are satisfied  with their personal care doctor, as do 77% of people covered by Medicaid.

We do know that there is a lot of discussion of choice of provider and whether you will be able to keep your current doctor if you change health plans.  Having a relationship with a medical provider is very important to some people and having to change providers is a big deal.  But other people go out-of-network or to providers not covered by their health insurance because they can’t find a provider in their network, or they think the quality of care provided by other health care practitioners is better than what their plan covers.

Other people switch providers within their health plan for different reasons.  I personally have switched my personal care physician within my HMO several times, and gone out of plan for other services, because I wanted to find someone who would answer my questions and treat me with respect.

Have you ever gone out of network (and maybe paid more) for medical care?  Have you ever switched providers within your plan? Why?  Do you feel “stuck” with  a provider because there are no others available?  Please post any experiences you have had that made you switch providers.  What do you think are the most important characteristics of a health care provider?  What would make you switch providers, or leave their care?  We’re interested in all providers, including your primary care provider but also dental, mental health, and other health care providers.

Please comment or send an email (on the “contact” page).

Having insurance doesn’t mean you don’t pay anything, or that health care bills aren’t a hassle.

In 2016, about 6% of working-age adults say they didn’t receive needed health care due to cost. The percentage is less for children and older adults. About 9% didn’t receive needed dental care due to cost (in 2015).

In 2016, the average annual premiums for employer-sponsored health insurance are $6,435 for single coverage and $18,142 for family coverage (your employer may pay a lot of this for you). Among covered workers with a general annual deductible, the average deductible amount for single coverage is $1,478. Workers or others with health savings accounts have to pay substantially more than this.  Even after the deductible, most people have to pay something when they visit a provider; usually between $10 and $40.  So, even with health insurance, you can pay a lot.

About a quarter of families with the say that they have had some trouble paying their medical bills.  This had decreased from 2011 among people under age 66, from 21.3% to 16.2% (43.8 million) in the first 6 months of 2016. Medical debt has been among the leading causes of bankruptcy for the last several years.

For people who pay claims for each visit, it can also be confusing and irritating to figure out how much you owe and what is covered.  For serious conditions and procedures you may pay out of pocket and then the  insurance company rules whether the benefit  is covered, which means you have to pay and then get reimbursed (maybe).

How much do you pay out of pocket?  How much of a problem are these payments?  Do you have problems getting reimbursed?  Can you afford your health insurance premiums?  Have you ever not received medical care you think you needed because you couldn’t afford it?  We would love to hear some real-life examples of the problems medical care costs have caused for you.

Please comment or send an email (on the “contact” page).

The first blog entry focused on what basic information we have about the experiences of people getting (or not getting) needed health care.  But let’s step back and think about why people get health care, and how people currently (or in the future) think about what health care they should get regardless of their ability to pay for it. Should only certain “vulnerable” people be guaranteed health care, or everyone? What services should always be included?  Which services are “optional” and should be allowed to differ by insurer?  How much people can be expected to pay out of pocket?   How much is too much to pay for private health insurance?

So here are some questions to think about when we’re discussing access to health care.

• If health care is not a right, why did Congress pass the Emergency Medical Treatment & Labor Act (EMTALA), which requires Medicare-participating hospitals (almost all of them) to provide emergency treatment? Why is emergency care guaranteed, but not other types of care? If a person does not chose to purchase health insurance (but could theoretically afford it), should they still be guaranteed emergency care?
• How much of insurance premiums should be returned to enrollees as benefits (the loss ratio)? For example, the Affordable Care Act requires insurance companies to spend at least 80% or 85% of premium dollars on medical care, with the rate review provisions imposing tighter limits on health insurance rate increases.
• What benefits, if any, should health insurers have to cover in order to qualify as health insurance (and not just catastrophic insurance)? What about dental care, mental health care, or substance use disorder care?  Should  they be separate policies (as dental care is usually now, but mental health and substance use disorder care are not)?  What about long-term care?
• How much should healthy people subsidize health care costs for ill or disabled people? In reality everyone might become ill or disabled at some point (or a family member might).
• Why do males complain about paying for pregnancy-related insurance coverage?  Did they have no responsibility for the pregnancy, or infant care? Is the responsibility entirely by the mother? Should women not have to pay for viagra in their policies?
• If the thought is that Medicaid should cover “the most vulnerable” people, how is that defined? Right now Medicaid covers more than 1/3 of (all) children, many disabled people, poor and low-income nursing home residents (often after they have spent down their assets), pregnant women (Medicaid covers more than 1/2 of all births), and in some states, the very poorest people.  If Medicaid funds are reduced, which of these populations should be considered “nonvulnerable”)?

These are just a few of the questions that must be considered when thinking about access to health services.  Please posts your thoughts, additional questions, and your experiences accessing the health care system.

Lately, there is a lot of talk about health care in the United States, but also a lot of misinformation.  We know some things based on national statistics about how many people get some types of health care; how easy it is for them too do so; and a few things about how much health care contributes to actual health, on average and for specific conditions.  But national statistics mask individual experience.  Do policymakers know how their proposals will affect individuals, or local areas?  What problems do you have getting specific types of health care (for example, dental  care, mental health care, substance use disorder services, preventive care, long term care, cancer treatment?) We are hoping that you  can briefly describe your experiences getting needed health services and if enough people respond, we can start to get an idea of the real consequences of being able to access needed services, or not.  There are a lot of anecdotes,  but policymakers dismiss them as not being representative of the real picture, or they take one example and say it applies to everyone.

Here are some things we know (primary sources are hyperlinked):

• The United States ranks first on the amount of money spent on health care and 37^th on health care performance.
• People with higher income live longer, on average, than people with lower income.
• People with health insurance get more medical care than those who are uninsured.
• More than one third of children are covered by Medicaid.
• Forty percent of adults age 19-64 with Medicaid coverage are currently working .
• A large number of families have medical debt that causes financial hardship (also see this article and this one).
• The average charge for a hospitalization for a heart attack is $81,197.00 (although most people pay less if they have insurance).

What we don’t know in any systematic way about access to health care and the impact of gaining or losing health insurance:

• How many medical providers treat privately insured, Medicare, Medicaid and uninsured patients (we know something about physicians but not other providers).
  • Are there people with insurance (either private or public) but can’t get appointments because providers won’t see them? Or are there just no providers around?
  • How far do people have to travel for different types of health care?  How does this differ by local area?
• The effects of not receiving care (or receiving bad or excessive care, or care in the wrong setting) on health and well being.
  • How does this differ by type of care or provider? What are the consequences of not receiving needed services that are not immediately life threatening  (for which you can go to the emergency room)? How many people suffer from dental pain because they have no access to dental care?   How hard is it to find a mental health provider?
• The effects of medical debt on health and well being.
• The effect on communities of people not receiving needed health care, or of the health care system on employment and community health.

If you want to contribute to this discussion, you could briefly write a paragraph about what you like, or don’t  like, about your ability to get the health services you need below.  We’re hoping to have different discussions/comments about different topics, for example dental care, long term care, therapies, access for people with  disabilities, people diagnosed with  cancer, etc.  But to start just say anything you want on the topic of how easy or hard it is to get health care, and what you would like to see improved, if anything.  If there is a particular topic related to health care access you would like to see discussed, just say so.  We will try to give you the information  that currently exists on the topic at the national level, but what we really want to know is your experiences in your local communities.