Sorry, We Don’t Take Obamacare
The growing pains of the health care act are frustrating patients.
THE NEW YORK TIMES
By ELISABETH ROSENTHAL
MAY 14, 2016
AMY MOSES and her circle of self-employed small-business owners were supporters of President Obama and the Affordable Care Act. They bought policies on the newly created New York State exchange. But when they called doctors and hospitals in Manhattan to schedule appointments, they were dismayed to be turned away again and again with a common refrain: “We don’t take Obamacare,” the umbrella epithet for the hundreds of plans offered through the president’s signature health legislation.
“Anyone who is on these plans knows it’s a two-tiered system,” said Ms. Moses, describing the emotional sting of those words to a successful entrepreneur.
“Anytime one of us needs a doctor,” she continued, “we send out an alert: ‘Does anyone have anyone on an exchange plan that does mammography or colonoscopy? Who takes our insurance?’ It’s really a problem.”
The goal of the Affordable Care Act, which took effect in 2013, was to provide insurance to tens of millions of uninsured or under-insured Americans, through online state and federal marketplaces offering an array of policies. By many measures, the law has been a success: The number of uninsured Americans has dropped by about half, with 20 million more people gaining coverage. It has also created a host of new policies for self-employed people like Ms. Moses, who previously had insurance but whose old plans were no longer offered.
Yet even as many beneficiaries acknowledge that they might not have insurance today without the law, there remains a strong undercurrent of discontent. Though their insurance cards look the same as everyone else’s — with names like Liberty and Freedom from insurers like Anthem or United Health — the plans are often very different from those provided to most Americans by their employers. Many say they feel as if they have become second-class patients.
This disappointment is fueling renewed interest in a “public option” that would supplement current offerings. That idea found support from both Senator Bernie Sanders and Hillary Clinton as the Affordable Care Act was making its way through Congress. It was taken up again last week by Mrs. Clinton, when she suggested allowing people 55 and over to buy into Medicare, the government-run insurance for people 65 and over, which is accepted by virtually all hospitals.
Some early studies of the impact of the Affordable Care Act plans are proving patients’ grumbling justified: Compared with the insurance that companies offer their employees, plans provide less coverage away from patients’ home states, require higher patient outlays for medicines and include a more limited number of doctors and hospitals, referred to as a narrow network policy. And while employers tend to offer their workers at least one plan that allows them coverage to visit doctors not in their network, patients buying insurance through A.C.A. exchanges in some states do not have that option, even if they’re willing to pay higher premiums.
Many of the problems may well be the growing pains of a young, evolving system, which established only broad standards for A.C.A. plans and allowed insurers — a large majority of them for-profit — considerable leeway in designing their exact offerings. The specific requirements and policing mechanisms vary by state, and are still works in progress.
Daniel Polsky, executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania, is among the researchers who have been studying the law’s effects on patients’ access to care. “We hear lots of complaints, but we really don’t know the extent of the problem because there’s still very little data,” he said.
The legislation created four tiers of insurance — bronze, silver, gold and platinum. The different levels represent the amount of medical costs a patient could expect their insurance to contribute: 60, 70, 80 or 90 percent. But within each tier there are dozens of plan designs that give buyers the choice of different premiums, deductibles and networks of doctors, among other things. And the options are different in each state. The A.C.A.’s target audience included both low-earning Americans — those too wealthy to qualify for Medicaid but too poor to afford commercial insurance — and those who could not buy insurance through an employer, either because they were self-employed or because their jobs for small companies didn’t offer coverage.
The research thus far suggests that the differences between plans offered through the A.C.A. and those offered by employers may be quite significant. A study in the policy journal Health Affairs found that out-of-pocket prescription costs were twice as high in a typical silver plan — the most popular choice — as they were in the average employer offering. In research conducted with the Robert Wood Johnson Foundation, Dr. Polsky found that 41 percent of silver plans offered a “narrow or very narrow” selection of doctors, meaning at best 25 percent of physicians in an area were included. The consulting firm Avalere Health found that exchange plans had 42 percent fewer cancer and cardiac specialists, compared with employer-provided coverage.
Some of the problems may have been predictable. When designing the new plans, for-profit insurers naturally tended to exclude high-cost, high-end hospitals with whom they had little clout to negotiate discounts. That means, for example, that as of late last year none of the plans available in New York had Memorial Sloan Kettering Cancer Center in their network — an absence that would be unacceptable to many New York-based employers buying policies for their employees. Another issue is out-of-state coverage, which many A.C.A. plans don’t offer aside from emergencies, and which is routinely offered in policies from companies — especially large ones — with workers in more than one state.
As a result, many parents who were excited that they would be able to keep their children on their policies until age 26 have discovered that this promise has gone unfulfilled. When Sara Hamilton of New York was shopping on the exchange for a plan to cover her and her two young-adult children — who live in distant states — she discovered that none of the plans covered doctor visits in those places.
And when Simon F. Haeder of the University of Wisconsin and his colleagues studied the plans sold on the California exchange, they found that they included 34 percent fewer hospitals than those sold on the open market and tended to exclude the priciest medical centers, like Cedars Sinai, a highly regarded hospital that runs the largest heart-transplant program in the country.
Plan size, of course, is not the only consideration. The research also showed that those limitations might not matter so much for patients’ health: The distance traveled and the quality of the providers was similar under both types of policies. He acknowledged, however, that California’s exchange, called Covered California, has higher standards for plans than others do, and those results may not be typical.
For certain patients, narrower networks can be attractive because they tend to have lower premiums. A recent analysis by the management consulting firm McKinsey & Company found that premiums were 22 percent higher for plans with broad, as opposed to narrow, networks.
Meanwhile, as researchers continue to evaluate the pros and cons of new exchange plans, patients are discovering the pitfalls.
In 2013, Angie Purtell of Tega Cay, S.C., bought a gold plan offered by Coventry Health Care. When notified that the plan would double its monthly premium the following year, to nearly $1,000, she went shopping again on the state exchange and chose a Blue Cross silver plan for $500. It was branded “Choice.”
But when she tried to visit her longtime doctor using the new plan, she found she could not. The doctor’s practice, while in South Carolina, was not covered because it is affiliated with the Carolina Medical Center, a few miles over the border in Charlotte, N.C.
In order to make smart choices, patients need far clearer and more accurate information about the plans’ restrictions as well as which doctors and hospitals are in the network. Yet such information is rarely available, and early research suggests that only a fraction of the doctors listed in some directories are available to see new patients.
“Now that you have the A.C.A., we really need to talk about what is an adequate network,” Mr. Haeder said. “But we can’t really talk about that until we know that the listings are accurate, and they’re not.”
ACROSS the country, lawmakers and regulators are refining the plans’ requirements to make sure they work better. And regulators are trying to mandate better information, provided in a more consumer-friendly format.
As of this year, the government requires all the plans listed on the national online exchange — used by 38 states — to provide accurate, up-to-date directories. But such directories are often hundreds of pages long, and there is little enforcement. Even the government advises consumers to double-check with their insurers.
The Centers for Medicare and Medicaid Services recently proposed that states develop quantitative requirements for adequate networks — how many specialists of a certain type, for example, are necessary in a specific geographic area. But after protests from insurers and some states, the agency settled — for now — on a more limited fix that allows states and insurers more time to address the problem.
Next year, the government will begin requiring insurers to label plans “standard” (an average number of doctors for an exchange plan) versus “broad” or “basic” for those offering more or less choice. A few states are enacting their own laws.
But health and consumer advocates say progress is too slow, often leaving patients in the dark as they struggle to buy and use the new plans. Even as conservatives in Congress and the presumptive Republican presidential nominee, Donald J. Trump, have vowed to repeal the A.C.A., many consumers just want the system to work better.
“I’m putting my energy into improving transparency and information,” Dr. Polsky said. “Otherwise, we’re headed to a poorly implemented strategy that just ticks people off.”