Moderated by Tom Sabulis
Continuing the conversation on the Affordable Care Act, a healthcare expert writes that, despite the failures of the federal website Healthcare.gov, consumers can still enroll, but they need to do legwork to find the right plan. A statewide doctors’ group says new insurance networks are restricting patient access to their doctors.
Commenting is open.
By William S. Custer
“Keep calm and carry on” was the slogan on a widely distributed poster in Great Britain just before World War II; it has been gaining popularity again just in time for the implementation of the Affordable Care Act. While the issues we face are far less harrowing than those Britons faced, it would be difficult to tell that from the rhetoric surrounding the ACA.
In truth, most Georgians will experience either no change or only a small change (1 percent or less) in premiums and benefits in 2014 as a result of the ACA. That is because more than two-thirds of Georgians have large-group employment-based coverage, or have Medicare or Medicaid coverage. Large employers do face additional costs in new taxes, and some will have to change their benefit plans, but the average costs of these changes will be between half-percent and 2 percent of premiums.
The Georgians most directly affected by the Affordable Care Act are those who purchase individual health insurance coverage, small employers and those currently uninsured. ACA’s goal is to allow those individuals access to the same health insurance coverage at the same prices as employees of large firms (and Congress, for that matter). It generally achieves that goal by fundamentally restructuring the individual insurance market for coverage purchased on the exchange or outside of it. While it has always been good advice, this year especially it is important for consumers to shop carefully for health insurance.
The number of insurers participating in the exchange, the number and types of plans, the features of each plan, and the premium each individual would pay has been known by the state and federal agencies setting up the exchange since early August, but it hasn’t been made available to consumers. Instead, consumers have been subject to a great deal of misinformation on the available options and their premium costs.
Consumers comparing health plans need to examine premiums, out-of-pocket costs under a plan and the range of choices of providers participating in the plan. The website Healthcare.gov was intended to give consumers that information, but its failures have been well documented. Consumers don’t need to use that website to enroll; they can apply by the phone or with a paper application. But the website’s failure means consumers will have difficulty comparing plans. Until Healthcare.gov is fully functional, consumers will need to do a bit of legwork to understand the choice of providers in each plan. That information is available on the each insurer’s website.
Healthcare.gov has created a workaround, so individuals can see the plans available to them in each region of the state. Readers can access this part of the website without delays and compare plans available in Georgia. The premiums listed here are not the exact premiums; it gives premiums in age ranges. However, there are calculators consumers can use get a sense of their total costs of coverage (premium minus subsidy, if any) on websites of the AJC (http://www.myajc.com/s/news/healthcare-georgia/), WebMD (http://www.webmd.com/) and Kaiser Family Foundation (http://kff.org/).
William S. Custer is director of the Center for Health Services Research at Georgia State University.
By William E. Silver
I’m guessing that there aren’t too many people in Georgia who aren’t aware of the technical problems that have plagued the recent launch of the Patient Protection and Affordable Care Act’s (PPACA) state-level, web-based ‘Health Insurance Marketplace’ – where the uninsured will compare and obtain health insurance policies.
I also suspect that most Georgians don’t know about a related development that could have far greater ramifications when it comes to their well being and peace of mind, which is an effort by health insurers participating in the aforementioned exchange to limit the number of physicians included in their “networks” as a way to reduce costs.
These companies are restricting the number of physicians that residents of this state have access to as a way of manipulating the marketplace, which limits patient choice and undermines the patient-physician relationship.
The insurers have seized on the new health insurance exchange as an opportunity to create smaller networks, which means that they will use an administrative exercise to pay the same physicians who see the same patients something less under the guise of a new commercial product simply because these physicians will be part of smaller networks that have less clout.
The health insurance plans in the PPACA-driven exchange have enabled health insurance companies to obtain new members (i.e., patients) with little consideration for what’s best for the community or the individual patient. This is especially true in the markets in the state where there’s just one insurance company providing the coverage.
Patients may also see higher out-of-pocket costs if they need to see a physician who is outside one of these narrower networks – especially if they require more complex care.
The health insurers in question have created networks of physicians (and hospitals) that are easier to control and manipulate than the ones traditionally seen in the commercial health insurance arena, for no other reason than being able to pay those physicians and other health care providers less. I know this is taking place because I work with physicians in every specialty and practice setting in the state on a daily basis in my role as the president of the Medical Association of Georgia.
Every Georgian should be concerned that the process and criteria that these companies use to determine which physicians are or aren’t in a given network lacks both clarity and transparency. It is also troubling to know that health insurers in the state are making these kinds of determinations without the physician’s knowledge or permission.
So what can we do as individual patients? Whether you obtain your coverage through the new state-level exchange or a private plan, I encourage you to contact your health insurance provider to ensure that you will continue to have access to the physician of your choice – one that’s in your community. It’s simply not right for an insurance company or the government to make that decision on your behalf. After all, we were told that we could keep our physician from the beginning.
Dr. William E. Silver is president of the Medical Association of Georgia, which represents more than 7,400 physicians.