What Obamacare doesn't cover: the little costs that rack up

[IIOY]

In a lot of ways, for a lot of Americans, the Affordable Care Act, aka Obamacare, has delivered precisely what its official moniker suggests: affordable health insurance.


Speaking on a purely personal level, the plans I could buy post-Obamacare carried monthly price-tags ranging from $350 to $700 – a far cry from the solitary plan available to me before, priced at $1,785 a month.

And yet, the cost of staying healthy isn’t always picked up by your health insurance company.


Under Obamacare, Americans may no longer have to choose between bankruptcy and getting medical treatment for life-threatening illnesses. But the burdensome costs of the routine stuff could become still weightier.

Indeed, even before President Barack Obama proposed the controversial healthcare reform policy that now bears his name, employers that offered insurance had been finding ways to shift more of the cost of their plans to employees.


Family members might once have been covered as part of a benefits package but now were covered at additional cost; employees were told they’d be picking up part of the cost of some of the plans (especially “extra” benefits, like dental or vision plans). As the years have passed, benefits themselves have become leaner, as both employers and insurers have sought to cut expenses.

Just ask Rita Cheng, a financial advisor at Blue Ocean Global Wealth in Bethesda, Maryland. She helps her clients cope with their rising costs – including medical expenses – and deals with the financial impact of her 15-year-old son’s chronic asthma.

“The co-payment for the inhaler he needs for his maintenance – to prevent a severe attack – used to cost me $7,” she says. “Then it went to $30. Then $60. Now it’s $100, every month.” In other words, she is now paying more than half the cost of the medication, with her insurance picking up the remaining $81.


“It’s not as if you have a choice about whether or not to use an asthma inhaler,” she points out.

Ironically, Obamacare may only have made matters worse for the cost of day-to-day healthcare including vision and dental plans.


People like Cheng who know that they’re going to be forking over a lot of money for stuff that isn’t covered by their insurance plan – co-payments, deductibles, or treatments after you’ve reached your annual maximum – can use pretax dollars from their paychecks to set up either a health savings account (HSA) or flexible spending account (FSA).


(Here's the difference in a nutshell: employers have the option of offering an FSA; if they don’t and you’re enrolled in a high-deductible health plan, you can set up your own HSA.)


Pre-Obamacare, there wasn’t any official maximum limit to FSAs. A number of employers set the contribution as high as $5,000.


So if you knew you’d be forking over a lot for your teenager’s braces, your husband’s dental work and your own arthritis medications, and that changes to your health plan meant you’d be shouldering more of the burden for routine office visits to doctors, you could set aside $3,000 or more.


Post-Obamacare? You’re limited to $2,500.

“With the arrival of Obamacare, I am seeing more complexity, including people finding that their longtime physicians are now out of network and have to be paid out of pocket,” Cheng notes.


It all adds up. For me, that means discovering that in my new network, there isn’t a single neurologist in my new network who is accepting new patients.


I’ve now found a great out-of-network doctor, but I’ll pay $2,000 a year on top of my new, affordable, Obamacare healthcare premiums to consult him. And let’s not even talk about the fact that the typical dental plan’s benefits max out at about $2,500: if you need two root canals, you’re done for the year (and you’ve probably still paid $1,200 out of your own pocket).

Heidi Leighton, a Maine office worker, already rations the frequency with which she takes Trexemet, the medication she uses to control her migraines. “It costs $5 a pill, and there’s no generic yet,” she says.

She frets about having to take a day off work to travel two hours each way to Bangor in order to have medically-necessary bloodwork at an in-network hospital. (She could have it done locally, and not lose a day’s wages – but then she’d have to pay $100 out of pocket.)


But it’s the insurance company’s policy on orthotics that really annoys her.


“As a child I had foot surgery to separate small bones that had fused together and now I need custom orthotics” in order to be able to stand without pain and remain physically active, even mobile. That’s about $120 a year – and the insurance company won’t pay a dime, even though without them Leighton risks ending up on disability.

“Any one of these costs on its own is no big deal, but if you add them up, it’s bad news, even though it’s somehow it’s never quite enough to qualify as a deduction against our income taxes.”

For many Americans, it’s going to feel as if new costs are sneaking up on us as a result of Obamacare in part, says Eleanor Blayney, consumer advocate for the CFP Board. It mandates that health insurance policies cover things that once weren’t required, like alcohol counseling or treatment for obesity. Women may end up getting a greater array of obstetrical and gynecological care and procedures covered, while children up to the age of 26 are covered.

“So as the costs of those requirements are priced in, other cuts may show up,” says Blayney.


Employers may decide not to cover healthcare for spouses; they may not offer dental policies or vision care, or may no longer subsidize those plans. UPS has already made headlines because of its decision to yank healthcare coverage for its employees’ spouses.

Clearly, “affordable” is all in the eyes of the beholder.

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[IIOY]

We've run into this with my Rx allergy medicine, which has gone from reasonable to ridiculous. I'm lucky because there are OTC alternatives (and luckily for me, a fabulous new one called Nasocort that has replaced both of my prescription allergy meds for now), but a lot of medicine isn't optional for folks. It makes sense for medical care and medicine prices to move beyond the $10 copay; I just don't know that anyone was prepared for how *much* prices would jump.

[noodleoo]

The problem is not what insurance companies cover. The problem is that medications (and health care in general) are extremely overpriced in the US. There is no transparency into pricing and bc people have insurance, there is no competition or incentive to comparison shop. The prices for meds and medical care are exorbitant compared to what the same drugs and procedures are priced abroad.

You should read the article Bitter Pill from Time magazine. It is eye opening (not in a good way).

[LoveTrains]

I agree that Nasocort is amazing!

[IIOY]

Apr 20, 2014 9:29:35 GMT -5 LoveTrains said:

I agree that Nasocort is amazing!

I'm convinced it's going to give me nose cancer because it's almost too good to be true.

[lilibet]

I think I need to look into Nasocort because my allergies are killing me.

I also thought I'd point out that a lot of the new ACA plans are not HSA compatible and apparently this was not clearly (if at all?) mentioned during the enrollment period. I've dealt with a number of pissed off people who want to set up an HSA and can't.

[Deleted]

We switched to a HSA about 5 years ago... back when Obamacare was just a twinkle in the democrats eyes.... A lot of what is written in this article was happening pre-Obama care. We went from a flat co-pay on prescriptions to some sort of "sharing".

As for the asthma inhalers that's not Obamacare's fault... that is the EPA that required they be aerosol free and now they are no longer available as a generic. I used to get my generic albuterol inhalers for about $7, now 1 inhaler is closer to $100.

[lys]

Many of the insurance policies offered on the exchange have huge deductibles before the insurance even kicks in their coverage. A $6000 deductible is just not affordable to many people who were hoping for lower costs out of pocket.

[gretchenindisguise]

Yeah, inhalers in particular were pre-Obamacare. Meds have been going up for years.

I'm happy people are starting to notice the craziness, but I'm annoyed they're pinning it on the wrong cause.

[Deleted]

Apr 20, 2014 17:00:49 GMT -5 lys said:

Many of the insurance policies offered on the exchange have huge deductibles before the insurance even kicks in their coverage. A $6000 deductible is just not affordable to many people who were hoping for lower costs out of pocket.

The plans and all plans as even employers have moved to HSAs with high deductibles... Our deductible is 8k before insurance kids in. It isn't for going to the dr for a cough. It is to protect you from bankruptcy if you end up in the mental hospital for a month, or develop breast cancer. They are also wonderful for people with expensive chronic diseases. It is nice to know you are "only" out of pocket $8k/yr vs having to pay 10% of every bill 

[irishbride2]

Apr 20, 2014 17:11:18 GMT -5 @septimus said:

Apr 20, 2014 17:00:49 GMT -5 lys said:

Many of the insurance policies offered on the exchange have huge deductibles before the insurance even kicks in their coverage. A $6000 deductible is just not affordable to many people who were hoping for lower costs out of pocket.

The plans and all plans as even employers have moved to HSAs with high deductibles... Our deductible is 8k before insurance kids in. It isn't for going to the dr for a cough. It is to protect you from bankruptcy if you end up in the mental hospital for a month, or develop breast cancer. They are also wonderful for people with expensive chronic diseases. It is nice to know you are "only" out of pocket $8k/yr vs having to pay 10% of every bill 

For many , 8k a year would lead to bankruptcy.

[Deleted]

Apr 21, 2014 4:09:49 GMT -5 irishbride2 said:

Apr 20, 2014 17:11:18 GMT -5 @septimus said:

The plans and all plans as even employers have moved to HSAs with high deductibles... Our deductible is 8k before insurance kids in. It isn't for going to the dr for a cough. It is to protect you from bankruptcy if you end up in the mental hospital for a month, or develop breast cancer. They are also wonderful for people with expensive chronic diseases. It is nice to know you are "only" out of pocket $8k/yr vs having to pay 10% of every bill 

For many , 8k a year would lead to bankruptcy.

8k might but those who couldn't afford a payment plan of 8K probably would qualify for medicaid under obamacare so we aren't talking the poorest of Americans. It might not be pretty but a family making 60k could afford 8k on a payment plan without resorting to bankruptcy unlike previously where they could end up with 100K in medical debt.

[irishbride2]

We couldn't handle 8k of medical debt every year on top of premiums. No way. You said chronic illness so that's every year. The only reason it wouldn't bankrupt is is my family would help but it would bankrupt, over time, most people who make what we make.

You're talking 21k in medical related costs a year at a minimum (when addinging premiums). On 60k?

[Deleted]

Apr 21, 2014 4:48:04 GMT -5 irishbride2 said:

We couldn't handle 8k of medical debt every year on top of premiums. No way. You said chronic illness so that's every year. The only reason it wouldn't bankrupt is is my family would help but it would bankrupt, over time, most people who make what we make.

You're talking 21k in medical related costs a year at a minimum (when addinging premiums). On 60k?

Our deductible with our HSA is 8K whether it is 1 person or the whole family. I only skimmed the healthcare.gov site to see if we'd get a better deal, but they all seemed to be some sort of large family deductible. 

We come out ahead with our HSA because we do have one family member with an expensive chronic illness and so we know just how much we are out each year. Jan and Feb sort of suck when you have to pay full price for medicines that cost $700 for a month supply, but otherwise it is pretty good. 

[IIOY]

Apr 20, 2014 13:20:18 GMT -5 @septimus said:

We switched to a HSA about 5 years ago... back when Obamacare was just a twinkle in the democrats eyes.... A lot of what is written in this article was happening pre-Obama care. We went from a flat co-pay on prescriptions to some sort of "sharing".

As for the asthma inhalers that's not Obamacare's fault... that is the EPA that required they be aerosol free and now they are no longer available as a generic. I used to get my generic albuterol inhalers for about $7, now 1 inhaler is closer to $100.

It's not just inhalers, though. My Rx meds jumped in price this year under our new plan. In conjunction with very high deductibles under Obamacare, it's understandable that people have sticker shock after being told they would save money.

[IIOY]

Apr 20, 2014 13:20:18 GMT -5 @septimus said:

We switched to a HSA about 5 years ago... back when Obamacare was just a twinkle in the democrats eyes.... A lot of what is written in this article was happening pre-Obama care. We went from a flat co-pay on prescriptions to some sort of "sharing".

As for the asthma inhalers that's not Obamacare's fault... that is the EPA that required they be aerosol free and now they are no longer available as a generic. I used to get my generic albuterol inhalers for about $7, now 1 inhaler is closer to $100.

It's not just inhalers, though. My Rx meds jumped in price this year under our new plan. In conjunction with very high deductibles under Obamacare, it's understandable that people have sticker shock after being told they would save money.

ETA: the article is clear that Rx costs have been going up for years. Its focus is the structure of coverage and its impact on OOP costs.

[Deleted]

Apr 21, 2014 5:56:07 GMT -5 IIOY said:

Apr 20, 2014 13:20:18 GMT -5 @septimus said:

We switched to a HSA about 5 years ago... back when Obamacare was just a twinkle in the democrats eyes.... A lot of what is written in this article was happening pre-Obama care. We went from a flat co-pay on prescriptions to some sort of "sharing".

As for the asthma inhalers that's not Obamacare's fault... that is the EPA that required they be aerosol free and now they are no longer available as a generic. I used to get my generic albuterol inhalers for about $7, now 1 inhaler is closer to $100.

It's not just inhalers, though. My Rx meds jumped in price this year under our new plan. In conjunction with very high deductibles under Obamacare, it's understandable that people have sticker shock after being told they would save money.

ETA: the article is clear that Rx costs have been going up for years. Its focus is the structure of coverage and its impact on OOP costs.

Unlike our traditional insurance plan, our HSA deductible includes our prescription drugs so even though some drugs are expensive they count towards the 8k.

[Deleted]

Apr 21, 2014 4:48:04 GMT -5 irishbride2 said:

We couldn't handle 8k of medical debt every year on top of premiums. No way. You said chronic illness so that's every year. The only reason it wouldn't bankrupt is is my family would help but it would bankrupt, over time, most people who make what we make.

You're talking 21k in medical related costs a year at a minimum (when addinging premiums). On 60k?

A family making $60k year is going to get some pretty generous tax credits to help pay for their insurance so they aren't paying the sticker price of $13k. More likely they are paying 3-4K/yr

[aurora]

Apr 21, 2014 7:41:36 GMT -5 asdfjkl said:

I think part (though not all) of what is happening here is that people who had verrrrrry little interaction with the insurance industry before either because they didn't have insurance or because they were playing around with high deductible low premium low pay out plans (and rolling the dice they wouldn't ever have anything more serious than an ear infection) are just now seeing how completely totally fucked up the insurance industry is.  I'll admit, I just skimmed the article, but I didn't see anything in there that was Obama's fault.  I just saw insurance doing what insurance does, which is provide the least amount of coverage for the most amount of money.  They've got some restrictions on the lengths they can go with that now, but I think beyond risk pooling, Obamacare is going to be good for forcing people to come to grips with the fact that insurance is NOT the best way to provide health care coverage.  I'm hopeful that what we're seeing is more people joining that "pool" of people.

This is what I was thinking, too.  All of these costs were increasing pre-Obamacare, so why would we expect them to stop because of a controversial new law? 

So many people pre-Obamacare had insurance coverage that was OK for day-to-day but would have been bankrupted in case of a major accident or illness.  Fortunately, most of these people didn't have such a health issue and were able to go about their daily lives, but it's still the case that they are better protected now.

Our insurance industry makes me more angry than almost any other industry in the U.S. 

[Deleted]

Apr 21, 2014 9:53:12 GMT -5 asdfjkl said:

Apr 21, 2014 8:48:39 GMT -5 aurora said:

This is what I was thinking, too.  All of these costs were increasing pre-Obamacare, so why would we expect them to stop because of a controversial new law? 

So many people pre-Obamacare had insurance coverage that was OK for day-to-day but would have been bankrupted in case of a major accident or illness.  Fortunately, most of these people didn't have such a health issue and were able to go about their daily lives, but it's still the case that they are better protected now.

Our insurance industry makes me more angry than almost any other industry in the U.S. 

Like the guy complaining that now his neurologist is out of network and none of the ones that are in network are accepting new patients.  Y'know because that never happened pre-Obama.  No one ever had their employer-based insurance provider change because their employer wanted to save money and suddenly all their kid's specialists are out of network and the one's that are in network have decidedly shittier credentials or aren't taking new patients.  

Hell, that was one of the reasons DH left his last job.  When the new company took over, the first thing they did was replace the BCBS PPO with a self-insured anthem-like insurance plan that covered absolufuckinglutely nothing.  AND they wanted to assign a "case worker" to us because PTS was such a heavy user of insurance and they wanted us to start running all of her appointments through them first to determine if there was a lower cost way to handle her care needs.   Thanks Obama?

Anesthesiologist and Radiologists are the worst for being out of network. Are any of them actually in a network?


I've had to fight coverage in the past because I went to an in-network hospital only to find out that the anesthesiologist and radiologist who I had no choice in choosing were out of network.  

[downtoearth]

I'm with asdfjkl - I've been seeing these changes for years - well before the ACA started. I've always worked in a small company and these changes have been happening for the last 10 years for small insurers - less coverage for more money over and over and over again. From 2004 to 2005 our insurance costs (as a company) went up 16% and our coverage for services went down about 8%. My company kept shopping around, but found only more expensive options. I paid $5k OOP after insurance (it was $8k total for a natural, hospital birth with zero complications and a 24 hour stay) to have my first kid in 2006 and we had "good" coverage according to the health insurance industry.

Enough personal rants, but as you can see I really think private insurance with for-profit companies is NOT the best way to provide consistent, fair, cost-effective, and patient-based health coverage for anyone. I think the ACA hasn't gone far enough yet and I'm glad people are now paying closer attention to the costs that their insurance companies are being charged and I'm glad they are getting pissed.

[lasagnasshole]

Apr 21, 2014 9:53:12 GMT -5 asdfjkl said:

Apr 21, 2014 8:48:39 GMT -5 aurora said:

This is what I was thinking, too.  All of these costs were increasing pre-Obamacare, so why would we expect them to stop because of a controversial new law? 

So many people pre-Obamacare had insurance coverage that was OK for day-to-day but would have been bankrupted in case of a major accident or illness.  Fortunately, most of these people didn't have such a health issue and were able to go about their daily lives, but it's still the case that they are better protected now.

Our insurance industry makes me more angry than almost any other industry in the U.S. 

Like the guy complaining that now his neurologist is out of network and none of the ones that are in network are accepting new patients.  Y'know because that never happened pre-Obama.  No one ever had their employer-based insurance provider change because their employer wanted to save money and suddenly all their kid's specialists are out of network and the one's that are in network have decidedly shittier credentials or aren't taking new patients.  

Hell, that was one of the reasons DH left his last job.  When the new company took over, the first thing they did was replace the BCBS PPO with a self-insured anthem-like insurance plan that covered absolufuckinglutely nothing.  AND they wanted to assign a "case worker" to us because PTS was such a heavy user of insurance and they wanted us to start running all of her appointments through them first to determine if there was a lower cost way to handle her care needs.   Thanks Obama?

I've mentioned this before but finding a psychiatrist in DC who takes insurance AND new patients is damn near impossible. But it was before Obamacare, too. I guess there are enough rich crazy people* to keep them in business without taking insurance. Obamacare does nothing to fix this, but I don't see how it makes it worse, either. 

*If you take this statement literally, it's like you don't even know me. 

[irishbride2]

Apr 21, 2014 7:10:02 GMT -5 @septimus said:

Apr 21, 2014 4:48:04 GMT -5 irishbride2 said:

We couldn't handle 8k of medical debt every year on top of premiums. No way. You said chronic illness so that's every year. The only reason it wouldn't bankrupt is is my family would help but it would bankrupt, over time, most people who make what we make.

You're talking 21k in medical related costs a year at a minimum (when addinging premiums). On 60k?

A family making $60k year is going to get some pretty generous tax credits to help pay for their insurance so they aren't paying the sticker price of $13k. More likely they are paying 3-4K/yr

Really? I have a really good tax accountant and we pay it all. 

Can you show me the code?

ETA: If its not clear, I'm not anti Obama Care. I just think we have father to go. 

[IIOY]

Apr 21, 2014 10:14:55 GMT -5 downtoearth said:

I'm glad people are now paying closer attention to the costs that their insurance companies are being charged and I'm glad they are getting pissed.

Amen.

[Deleted]

Apr 21, 2014 10:24:59 GMT -5 irishbride2 said:

Apr 21, 2014 7:10:02 GMT -5 @septimus said:

A family making $60k year is going to get some pretty generous tax credits to help pay for their insurance so they aren't paying the sticker price of $13k. More likely they are paying 3-4K/yr

Really? I have a really good tax accountant and we pay it all. 

Can you show me the code?

Did you attempt to go on the exchange enter all your tax info and try to purchase health insurance? 

If I recall correctly, you could be screwed because you live in a state that decided not to expand medicaid. 

[irishbride2]

Apr 21, 2014 10:33:26 GMT -5 @septimus said:

Apr 21, 2014 10:24:59 GMT -5 irishbride2 said:

Really? I have a really good tax accountant and we pay it all. 

Can you show me the code?

Did you attempt to go on the exchange enter all your tax info and try to purchase health insurance? 

If I recall correctly, you could be screwed because you live in a state that decided not to expand medicaid. 

I have employer provided insurance so I do not qualify for the exchange. I just have to pay like crazy. I'm hardly the only one.

We need to go farther. 

[ajj]

Apr 20, 2014 9:34:04 GMT -5 IIOY said:

Apr 20, 2014 9:29:35 GMT -5 LoveTrains said:

I agree that Nasocort is amazing!

I'm convinced it's going to give me nose cancer because it's almost too good to be true.

It's the only thing that keeps my allergies in check, too.

[penguingrrl]

The private for-profit industry being in charged of medical decisions has to change. End of story. In 2012 we would have had yo declare bankruptcy due to medical costs had MIL not helped us out. I spent one night in an in network hospital having been brought in by ambulance barely breathing. I was assigned to see cardio thoracic surgeons, a pulmonologist and several other specialists, not a single one of whom was in network. Aetna told me it was my responsibility to ensure any doctor who saw me was in network regardless of circumstances. Because when surgeons are in there telling me they think the scar from surgery I had at birth has reopened at 31 asking if the doctor assigned to fix it accepts aetna should totally be my first concern.

That one incident, which ended up not being surgical, and involved a single night in the hospital ended up costing us $7K OOP. The hospital wrote off our portion of the hospital bill as charity care because our HHI was under $40K, so that number isn't included. The specialists eventually were able to get coverage as in network providers after 6+ months of fighting, but they were also allowed to charge us above and beyond what aetna allows since they aren't in network. One surgeon consulted with me for under 10 minutes, got $400 from aetna and went after me for another $1600. Charity care does't extend to private practice out of network physicians assigned to you by the hospital while you're bare;y conscious, FYI.

[earlgreyhot]

Apr 21, 2014 11:22:28 GMT -5 penguingrrl said:

The private for-profit industry being in charged of medical decisions has to change. End of story. In 2012 we would have had yo declare bankruptcy due to medical costs had MIL not helped us out. I spent one night in an in network hospital having been brought in by ambulance barely breathing. I was assigned to see cardio thoracic surgeons, a pulmonologist and several other specialists, not a single one of whom was in network. Aetna told me it was my responsibility to ensure any doctor who saw me was in network regardless of circumstances. Because when surgeons are in there telling me they think the scar from surgery I had at birth has reopened at 31 asking if the doctor assigned to fix it accepts aetna should totally be my first concern.

That one incident, which ended up not being surgical, and involved a single night in the hospital ended up costing us $7K OOP. The hospital wrote off our portion of the hospital bill as charity care because our HHI was under $40K, so that number isn't included. The specialists eventually were able to get coverage as in network providers after 6+ months of fighting, but they were also allowed to charge us above and beyond what aetna allows since they aren't in network. One surgeon consulted with me for under 10 minutes, got $400 from aetna and went after me for another $1600. Charity care does't extend to private practice out of network physicians assigned to you by the hospital while you're bare;y conscious, FYI.

Our system is so fucked up.

[penguingrrl]

Apr 21, 2014 11:25:42 GMT -5 earlgreyhot said:

Apr 21, 2014 11:22:28 GMT -5 penguingrrl said:

The private for-profit industry being in charged of medical decisions has to change. End of story. In 2012 we would have had yo declare bankruptcy due to medical costs had MIL not helped us out. I spent one night in an in network hospital having been brought in by ambulance barely breathing. I was assigned to see cardio thoracic surgeons, a pulmonologist and several other specialists, not a single one of whom was in network. Aetna told me it was my responsibility to ensure any doctor who saw me was in network regardless of circumstances. Because when surgeons are in there telling me they think the scar from surgery I had at birth has reopened at 31 asking if the doctor assigned to fix it accepts aetna should totally be my first concern.

That one incident, which ended up not being surgical, and involved a single night in the hospital ended up costing us $7K OOP. The hospital wrote off our portion of the hospital bill as charity care because our HHI was under $40K, so that number isn't included. The specialists eventually were able to get coverage as in network providers after 6+ months of fighting, but they were also allowed to charge us above and beyond what aetna allows since they aren't in network. One surgeon consulted with me for under 10 minutes, got $400 from aetna and went after me for another $1600. Charity care does't extend to private practice out of network physicians assigned to you by the hospital while you're bare;y conscious, FYI.

Our system is so fucked up.

Yes it is. Had we not had someone able and willing to bail us out we would have had to declare bankruptcy over medical debt despite being insured by a plan that met ACA minimum requirements.