By M.G. Oprea • The Federalist
It’s that time of year. No, not New Years. It’s Obamacare enrollment time—that is, if you’re unfortunate enough to not have employer-sponsored health insurance.
There’s been a lot of media coverage lately about rising premiums. But the headache isn’t just financial, although that’s certainly part of it. With more insurance providers fleeing the individual market and coverage becoming worse and worse, getting the care you need can feel almost impossible.
To illustrate, I’d like to share my own experience buying insurance on the Obamacare exchange and trying to get treated for a chronic health problem.
My Health Insurance Couldn’t Be More Frustrating
For several months now I’ve been having nearly constant migraines or headaches and frequent vertigo. More than an inconvenience, this type of illness makes it hard to use a computer—where I do all of my work.
After five months with an excellent ear-nose-and-throat (ENT) doctor, as well as multiple rounds of steroids and antibiotics (not to mention ripping out half of my house doing mold remediation), we’ve come to the conclusion that I need sinus surgery.
Until September, my doctor (let’s call him Dr. A) was covered under my health insurance provided through the University of Texas. However, when I left the university and started working for myself, I had to begin buying health insurance on the individual market. The insurance options were limited so I bought a plan with Scott and White. This insurance, however, didn’t cover Dr. A. In fact, it only covered three ENTs in Austin.
One of these three doctors—let’s call him Dr. B—was well reviewed and liked by Dr. A. Great, problem solved. I get surgery with Dr. B and I’ll be in good hands. When I called Dr. B’s office to make an appointment last week and told them I have Scott and White, they said that they do indeed take that insurance. Wonderful.
Even Insurance Providers Have Had Enough
But there’s a catch. My health insurance covers office visits with Dr. B, but doesn’t cover surgeries with him. Wait, what?
That’s right, Scott and White only covers surgeries that are done in their hospital system, rather than in the far less expensive—and less dangerous— outpatient surgical centers. Dr. B, although a highly regarded ENT, doesn’t have admitting privileges in their hospitals.
Alas, this doesn’t matter. My insurance is being cancelled at the end of the year because Scott and White is withdrawing from the individual market in Texas. And they’re not the only ones. It turns out that several big insurance providers are leaving the individual market at the end of 2016, including Cigna and Aetna, the third largest provider in the country. This is happening all over the country.
The only plans that are available for purchase in Texas for next year are HMOs or EPOs with highly restrictive networks. Half of those are Blue Cross Blue Shield Blue Advantage HMO plans. The other half is some provider called Ambetter (an Orwellian name if there ever were one).
And the Headaches Aren’t Over Yet
Thankfully, according to ehealthinsurance.com, Dr. B is covered by the BCBS plans. So, I called his office again and made sure there’s nothing tricky with BCBS like there was for Scott and White. The receptionist informed me that while Dr. B does take BCBS, he doesn’t take BCBS Blue Advantage HMO plans.
Unfortunately, that’s the only BCBS plan available for purchase. BCBS of Texas stopped offering individual PPO plans at the beginning of 2016. They reportedly made this decision after individual market claims exceeded premiums by $400 million in 2014.
So I’m back to square one, with no ability to buy insurance that will allow me to go to either of these doctors or to buy a PPO, no matter how much money I have.
What’s even more frustrating is that, even if Dr. B did accept an HMO plan, I would first have to go to a primary care physician to get a referral to see a specialist. Never mind that I have five months of medical records with a specialist and a CT-scan showing that I need surgery. What’s more, getting a referral approved by an insurance company requires a herculean effort.
What’s the Solution For People Like Me?
To illustrate, a good friend of mine has had a shoulder injury for years that recently got way worse. As a self-employed lawyer, he has an HMO bought on the individual market. It took over a month to get approved to see an orthopedist, meanwhile he’s in moderate to severe pain and wearing a sling. Even his doctor admitted that getting in to see a specialist was a long shot.
But let’s say I were able to get that sought-after referral, I’d still have a deductible upwards of $7,000, unless I wanted to pay $500 a month for insurance. In that case, the out of pocket max is still fairly high.
So what’s my solution? I’m going to get surgery at the Surgical Center of Oklahoma, and pay for subsequent ENT check ups with Dr. A out-of-pocket.
The Surgical Center of Oklahoma is operated by doctors and anesthesiologists that work out prices directly with the patient. They charge a flat fee with no hidden costs. My surgery will cost $3500 plus the trip to Oklahoma City (thankfully just a six hour drive for me). This is potentially thousands of dollars less expensive than going through an insurance plan bought on the individual market.
This Is Healthcare In a Post-Obamacare World
This wouldn’t be the first time I’ve negotiated a price directly with a healthcare provider since getting my Obamacare-compliant individual insurance. I worked out a price I could afford with Dr. A and did direct pay to get a CT-scan of my sinuses in October.
Rather than go through insurance, which wouldn’t pay for the CT-scan anyway (at least not until I reached my $6,000 deductible), I called around and found the cheapest imaging center. You see, they don’t want to deal with insurance companies either, so they offer an enormous discount if you pay at the time of service. I was able to get a CT-scan for $247.
At the end of the day, I’m paying hundreds of dollars a month for an insurance plan that doesn’t cover the doctors I need to see and has such a high deductible that I end up paying for most costs out of pocket anyway. And it doesn’t even allow the use of a Health Savings Account.
Maybe there’s something I missed. Maybe there’s some fantastic plan out there, one that neither me nor my husband (who worked for years in healthcare policy) nor my lawyer friend could figure out. But I doubt it. This is just the reality of getting health care in the post-Obamacare world.