The woeful state of health care in the United States has made the country into something that would be a laughingstock, if the stakes weren’t so high. While most other Western nations have managed to create functional (though by no means perfect) systems for ensuring that residents are connected with health services, the United States flails within a system that primarily benefits private insurers, pharmaceutical companies, and hospital conglomerates. Attempts at reform under the Obama Administration have proved difficult. While residents were never promised single payer healthcare (the most obvious solution to the country’s troubles) to begin with, the actual level of health care reform differs radically from that advertised.
Effectively, “Obamacare,” as its known, acts as little more than a giant subsidy for insurance companies, maintaining the myth that the market is capable of regulating itself to deliver the best services. Despite ample evidence to the contrary, the government appears to be sticking to its guns, and the results as the insurance exchanges touted as a solution open for business are developing into a massively tangled mess.
Describing the way health care works in the United States is challenging to those outside the system, and integrating Obamacare (or the Affordable Care Act) makes it even more complicated. Residents of the United States have a choice between buying health insurance to assist with paying for health care needs, or remaining uninsured and paying cash. Among uninsured patients, some qualify for sliding scale, financial assistance, or government programs like Medicaid. Older adults transition to Medicare, a government benefit, and special benefits programs are also available through the Veterans Administration and to members of Congress.
The patchwork of systems don’t actually directly provide health services: what they provide is funding for health services (in most cases—the VA actually runs health care facilities). Consequently, when a patient visits a doctor, the doctor may be out of network (as with many private insurance companies) or unwilling to provide care (some doctors refuse new Medicaid patients, for example, because billing is complex and can require lengthy fighting with the insurance company to authorise charges, which small offices don’t have the staffing or time to do in order to recover funds for services). With health outcomes in the United States at shockingly low standards in comparison to other Western nations, the goal of health care reform was to make health care more financially accessible to all—but the result has been to compel people in the US to buy health insurance, which may or may not provide health care depending on individual circumstances.
Under Obamacare, insurers may no longer deny coverage for preexisting conditions, a serious issue historically in the United States, and they need to provide a basic standard of care at the copper, silver, gold, and platinum levels of coverage offered under the state exchanges. These exchanges were set up to provide uninsured people or those with insurance who wanted to switch with access to an affordable insurance market. Subsidies are available for people who meet income standards, and half of the states also took advantage of the Medicaid extension, which raised the income cap on Medicaid to allow more low-income people to get into the program with minimal expense for individual states.
Proponents argue that insuring the entire country creates equal health coverage, and by compelling all people to participate in health insurance programmes, the cost of insurance is distributed. Thus, people who have limited health care needs help to fund those who have more extensive needs. This means that insurers are no longer burdened with high-cost patients, which is a remarkably capitalist approach to a basic human right.
Already, though, the implementation of Obamacare has been troubled. Many conservative states have refused the Medicaid expansion in a form of perverse pride, insisting that they won’t accept federal funds. This leaves their low-income residents, who are still subject to the insurance requirement, in a dangerous position. Furthermore, many insurance customers are receiving cancellation notices informing them that their policies do not meet the Obamacare standards and are coming to an end, but they are having trouble accessing new policies. This runs contrary to the claim that patients would be allowed to keep their insurance if they liked their plans, and has triggered chaos as the government attempts to determine what to do, considering options like extending deadlines and temporarily extending these soon-to-be-outdated policies to ensure that coverage gaps don’t occur.
Meanwhile, in California, I attempted to sign up for health insurance in order to comply with the law and avoid the fine that will be levied on uninsured people.
I had weighed the costs and benefits of Obamacare closely, and was fairly certain that it was actually more cost-effective to remain uninsured, despite multiple complex health problems, than to pay for insurance, cover my deductible, manage copays, and pay out of pocket for everything my insurance wouldn’t cover. Yet, I wanted to do my due diligence, and thus, I set out on what turned out to be a grim and unexpectedly personal look inside the chaos that surrounds the rollout of the state exchanges.
Supposedly open on 1 October, the exchanges as a whole were immediately rife with problems as user traffic crashed Healthcare.gov, the federal site providing information about the exchanges and administering insurance plans for those living in states without exchanges. California maintains its own website, Covered California, which, like Healthcare.gov, remained down in the early days of October. By the middle of the month, Covered California was allowing visitors to shop and compare plans, but not to actually buy them. It wasn’t until late October that the site actually permitted me to go through the enrollment process.
Notably, California’s rollout was allegedly one of the smoother across the country.
The site has significant accessibility issues, including frequent in-browser crashes, glitches, and hangups along with a confusing layout. While the signup process is ostensibly very short, consisting of a series of brief questions about me and my residence, it took much longer than necessary due to problems with the backend coding; and some Californians, especially those lacking computer literacy, gave up with the process altogether, turning to their insurance agents instead.
A gentleman who went to his insurance agent informed me that his agent was as confused as he was. His agent hadn’t received information about the available plans and wasn’t sure which insurance product to sell him, and his agent also reported concerns about how he would be compensated; agents normally receive a commission for insurance sales, but the exchanges are designed to be direct-to-consumer. If consumers turn to insurance agents for assistance because the system is too difficult to use, their agents have no assurance of consideration for their time and expertise. Ultimately, the gentleman left without a policy, with his insurance agent promising to call within several weeks.
At the end of the process, Covered California presented me with my options, strongly recommending Platinum level plans given my health problems. Thanks to my remote geographic location, only two insurers offered such coverage in my area, both for approximately $380 USD per month. Each plan offered identical standard benefits under the terms of ACA, but, curiously, it wasn’t possible to look at the actual insurance contract before signing.
Health insurance can be an expensive product, especially in the case of these platinum plans. The annual premium would be $4,559 with Blue Shield’s Platinum EPO, for example, with the plan capping out-of-pocket expenses at $4,000; I would spend $8,459 before all my health expenses would be covered by insurance. This, however, is primarily theoretical, because I still don’t know what is actually covered, and which exclusions may be present in the fine print.
US insurance companies have made an art form of denying coverage under the terms of the contract, making it absolutely critical to be able to read said contract before purchasing an insurance product. Particularly for those with known health care needs that could be subject to denials or lengthy battles with insurance companies (after high cash expenses to cover a procedure, treatment, or device while waiting for insurance approval), insurance contracts can become documents laden with red flags. Thanks to mental health parity, built into ACA and health care reforms, insurers can no longer dodge many mental health services, for example, but it’s still a concern: would my insurance cover my therapist? Would my therapist be willing to start billing an insurance company for his services, given that medical billing adds expenses to his practice?
Which medications and procedures will my insurer pay for? Would it fight surgical procedures that it didn’t deem strictly necessary, even if my doctor felt otherwise? Would it refuse to cover off-label or ‘experimental’ treatments? Notably, these denials of coverage are not evidence-based in the sense of covering the best option for the patient, as seen in evidence-based applications of coverage in nations with single-payer health care. Instead, they are focused on saving the insurer money, regardless as to whether the treatment is effective and appropriate.
Like many sensible consumers, I refuse to make a large-scale financial commitment without reading the associated contract. While Covered California has slowly been improving its website over time (between the end of October and the middle of November, it had addressed many glitches and made plan information easier to read, for example), it still hasn’t offered a fundamental piece of information that should be readily available: the actual details on what consumers would be getting for their $380 each month.
As of now, I remain uninsured—although Covered California helpfully reminds me that I have until 28 November to sign up in order for my coverage to take effect in time to avoid fees.