It's open enrollment season! Every year in November and December, everyone has the chance to re-evaluate their health insurance and change plans as needed. I want to take this opportunity to make sure everyone knows their options.
In the U.S., our healthcare system is primarily employer-based. Most people obtain health insurance through 1) their jobs, 2) Medicare, if over 65 or disabled, 3) Medicaid, for lower incomes, pregnant women, and children, 4) the military or Veteran's Administration, or 5) figuring it out on their own. The focus of our discussion today will be the people who are stuck trying to navigate this complex system on their own.
Who does option 5 apply to?
- Employees at a company with <50 employees. While some employers of this size do offer health insurance, they are not mandated to do so through the Affordable Care Act (ACA).
- Self-employed individuals (freelancers, small business owners, contract employees)
- Part-time employees
- Unemployed individuals (seasonal workers, laid off workers, stay-at-home parents, etc.)
- Anyone who retires before the age of 65
More than 15% of the population of the United States falls into this group, and they have to either find an affordable option for health insurance or go without.
It turns out, purchasing health insurance on your own is incredibly confusing and expensive. It will come as no surprise to you that, in 2019, 9.2% of the population went without health insurance. That's 30 million Americans skipping their preventative care, and praying they never have an emergency or health problem arise.
It's important to note these are pre-COVID numbers. Between February and May 2020, an additional 5.4 million Americans lost their health insurance after losing their jobs.
I also want to note that these numbers don't even include those who are underinsured. People who are underinsured have insurance, but their out-of-pockets costs are still so high when going to the doctor that they still avoid seeking medical care because it's unaffordable. A Gallup poll in 2019 revealed 33% of people delayed treatment for any medical problem due to cost. And 25% of people reported delaying treatment for a serious health condition. If you have health insurance, but your deductible is $10,000, you are on the hook for the first $10,000 of your care. And even when you reach your deductible, you are still responsible for a certain percentage of your costs.
With those numbers in mind, it's worth asking, "what's the point of having health insurance, if I can't even afford to go to the doctor with insurance?" That's a valid question. Health insurance does not equal healthcare. Think of health insurance as bankruptcy insurance. The costs of healthcare are so outrageous, that one trip to the emergency room or hospital is enough to bankrupt most families. In fact, 2 out of 3 bankruptcies are due to medical bills. There are so many examples of this, and anyone who had received a medical bill in the mail can relate to the sticker shock. A friend of mine (who has insurance, thankfully) recently went to the ER with abdominal pain, ended up having acute appendicitis, and needed surgery to remove her appendix. Her bill, without insurance, would have been $30,000. Unfortunately, none of us can predict when we'll be involved in an accident, have a serious disease like cancer or heart problems, or need emergency surgery.
So let's review the choices you have for your health when you're stuck figuring out it out on your own.
1) Health insurance through the ACA marketplace
At this time, this option remains very expensive unless you qualify for subsidies, i.e. discounts based on your income. For a single person, you fall into this category if you make between $12,490 - $49,960 yearly. For family of four people, you qualify for discounts if the household income is between $25,750 - $103,000 annually. These discounts are in the form of tax credits that are applied when you get the insurance (you don't have to pay the full amount and then wait for tax time to get a refund).
I recommend checking out https://www.healthcare.gov/ to input your information and get an idea of your costs.
2) Health insurance through a private broker
If you can navigate the healthcare.gov website, I would recommend starting there. If you're not sure what your needs are for your family, there are brokers that will recommend plans available through the ACA marketplace. Private brokers can also help you buy insurance plans that are outside the marketplace, from individual insurance companies. If you qualify for subsidies, you can only get those by buying health insurance through your state marketplace (healthcare.gov). If you do not qualify for subsidies, it may be worth getting quotes from a private broker to see if you can find better and cheaper coverage outside the marketplace.
3) Medicaid
You might be surprised to learn you qualify for Medicaid. Medicaid is extremely low-to no-cost insurance administered by states. Medicaid expansion, which occurred in many states when the ACA was passed, greatly increased the number of people who were eligible for Medicaid. In Ohio, where Medicaid expansion occurred, an individual making less than $17,609 qualifies for Medicaid, and a family of four making less than $36,156 (prior to Medicaid expansion, those limits would have been $12,760 and $26,200 respectively.) Pregnant women and children also qualify for Medicaid at higher income levels.
The easiest way to determine your Medicaid eligibility is to search for your specific state's Medicaid page. In Ohio, you can check eligibility and apply at: https://benefits.ohio.gov/ .
4) Health Shares
Health shares are an interesting option, particularly for people who are fairly healthy. Initially a religious phenomenon, health shares now apply to groups of people with both religious and ethical/moral affiliations. These arrangements originated in communities like the Amish and Mennonites, who pool money together to help afford care for everyone in the community. In the U.S. there are many Christian health shares, as well as non-religious options like Sedera, which simply asks their members to commit to living healthy lifestyles.
Why would you choose a health share over insurance? The only real reason would be to save money on monthly premiums. Otherwise, they have several downsides compared to health insurance. First, they typically do not accept members with pre-existing conditions, and if they do accept you, they won't consider anything related to your pre-existing condition to be "shareable" (meaning, you won't receive payments from the pool of money for that pre-existing condition.) Secondly, there is often a cap on how much they will pay out per member. There are many reports of members having an expensive emergency only to find out the cost was above what the health share was willing to pay. Thirdly, and most concerningly, the health share has complete discretion about what they pay for, and because they are not health insurance, they are under no legal obligation to pay any claim submitted.
In short, if you're a healthy individual and want to have some back-up in case of an unexpected medical emergency like an ER visit or short hospitalization, a health share is probably a good option to check out. Google health shares in your state to review your options, and make sure you look for some reviews and experiences from prior members.
5) Direct Primary Care
Ah, FINALLY we have reached the best part! Now, I am a direct primary care (DPC) physician, but first and foremost I am a physician - I took an oath to recommend what is best for my patients, and I have always thought about that in medical as well as social, emotional, and financial terms. So in short, I want everyone to have the care that is best for their individual circumstances, whether that includes my practice style or not.
Direct primary care is a monthly membership program. Patients pay their doctor a monthly fee, and all of their primary care needs are included: physical, sick visits, telehealth visits, as well as many procedure and urgent care issues. Most direct primary care doctors also offer at-cost medications and labs, because they are interested in providing great care and saving their patients from the usual high mark-ups of medicine. It's different from concierge care, because the fees are much lower, and DPC physicians do not charge double (they're not charging the fee AND health insurance). The average fees are around $75/month for an adult. It's different from a typical practice, in that DPC doctors have a smaller patient panel of patients to allow for longer patient-doctor visit times and increased communication, with the added feature of price transparency. (At my last non-DPC practice, it nearly took an act of God to find out what a Shingles vaccine would cost my patient who wanted to pay cash!) In a traditional practice, as doctors we really have no idea what our services and other procedures are costing our patients. In direct primary care, helping our patients understand and navigate the financial impact of healthcare is part of our mission.
Direct primary is not insurance, and if you have an emergency or need a consultation with a specialist, you'll either want to rely on help from your insurance or pay out of pocket. Some health shares, like Sedera, offer their members a discount on their monthly premium if they see a direct primary care doctor, because they know it will minimize costs. Since estimates show that 80-90% of health problems can be handled by a primary care doctor, the vast majority of your care will occur through your DPC doctor. Additionally, as DPC doctors know their patients very well and have more time to invest in their care, they are also more likely to manage problems themselves, rather than referring every little thing to a specialist.
You should consider direct primary care if any of the following apply: 1) you need a great primary care doctor, 2) you have high deductible health insurance, 3) you have no insurance, 4) you need a primary care doctor that has more time to spend with you, and better availability when you need him/her. While I would never recommend DPC as a replacement for insurance, if you're going without insurance anyway, I would strongly recommend a direct primary care doctor to make sure you are preventing health problems and managing issues early. (Ex: it's much better to manage your high blood pressure when it develops at age 30, than wait until you have a stroke years later. Without screening, you'll never know you have high blood pressure until it's too late, as it usually doesn't cause any symptoms.)
You can find a direct primary care doctor near you by checking out this map: https://mapper.dpcfrontier.com/
6) Cash pay at a traditional practice
Say you don't have insurance and you just decide you'll save up and pay cash when you need to go to the doctor for check-ups, sick visits, etc. That's a viable option. Just make sure you are setting money aside each month so you actually go to the doctor when there's a problem (and for preventative care). Cost is another issue; even though many doctor's offices offer cash pay discounts, you're still paying a lot more than insurance companies pay doctors for the same service. Expect to pay $200-400 for a doctor's visit, plus any additional fees the office decides to tack on (ex: facility fees). Labs and radiology are also quite expensive when you're paying cash on your own: look for labs and independent imaging centers that offer cash pay prices. You could save thousands on scans like an MRI just by getting it at an independent imaging center compared to a hospital outpatient radiology department. For medications, ask your doctor if a generic medication is appropriate. You can look medications up on the app GoodRx to find which pharmacy near you offers the lowest prices.
To sum up, make sure you're reviewing your options for healthcare. I strongly believe that everyone should have a great primary care doctor and some level of health insurance to protect your finances from crazy medical bills. I realize that it's easier to say that than to find a great PCP and afford health insurance. I hope this information is helpful in navigating the complex healthcare system we have here in the U.S.
Please share this with any friends or family members that are living without insurance or struggling to afford medical bills despite having insurance. Feel free to reach out to me with any questions at dr_moini@emeralddpc.com. Promoting access to affordable healthcare is one of my passions, and I'm happy to help anyone trying to figure things out on their own.
References:
Konish, Lorie. 2019. "This is the real reason most Americans file for bankruptcy." CNBC online, accessed via https://www.cnbc.com/2019/02/11/this-is-the-real-reason-most-americans-file-for-bankruptcy.html
"Health Insurance Coverage of the Total Population" Kaiser Family Foundation. https://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
"Medical Bankruptcy: Still Common Despite the Affordable Care Act" 2019. American Journal of Public Health https://ajph.aphapublications.org/doi/10.2105/AJPH.2018.304901?eType=EmailBlastContent&eId=a5697b7e-8ffc-4373-b9d2-3eb745d9debb&=&