Obamacare's Problem With Patients as Shoppers

In the next three months, as many as 13 million Americans are expected to shop for health insurance policies in the Obamacare marketplaces, counting people who signed up last year and millions shopping for the first time. They’ll mostly be buying plans with high deductibles—typically they’ll have to pay more than $2,000 for medical care before the insurance policy takes over. That means that after they shop for health plans, they’ll have an incentive to shop around for medical care, too.

All this shopping is a big departure from how Americans used to get health care. For most of the past half century, health insurance was a benefit provided by employers or the government. People who didn’t have it from one of those sources were often out of luck, especially if their medical needs made them expensive to insure. The Affordable Care Act helps many of them get coverage, but not as a straightforward benefit such as a company health plan or Medicare. Instead, it turns patients into consumers.

President Obama suggested last year that shopping on healthcare.gov would be like buying plane tickets on Kayak or a television Amazon—easy, in other words. Unfortunately, the information most people need to make good choices is often confusing, hard to find, or simply doesn’t exist. “I always liken it to sending people into Macy’s blindfolded, and you’re supposed to buy a shirt efficiently,” says Uwe Reinhardt, a Princeton health economist. “You come out with a pair of shorts with hearts on it.”

Set aside the website’s disastrous initial launch last year. Even once it was repaired, consumers were still missing clear, reliable answers to questions that any shopper should ask: Will my doctor take this insurance plan? Will it pay for the medicines I take? If I have an unexpected medical problem, how good is the care available to me, and how much will it cost? Given my health, financial circumstances, and risk tolerance, which plan is the best for me? “For a marketplace to function, consumers need to have really good information about what the different plans are offering,” says Karen Pollitz, a senior fellow at the Kaiser Family Foundation. The ACA originally intended to make much more information about health plans available, such as data about how many claims a health plan denies and how many people leave the plan. Reporting those transparency measures has been delayed.

Aaron Albright, a spokesman for the Centers for Medicare and Medicaid Services, which oversees healthcare.gov and state-run exchanges, declined to make officials available for an interview. In response to a list of detailed questions about how consumers would be able to navigate the marketplace, he sent a link to the revamped healthcare.gov website.

Finding out whether an insurance plan includes a particular physician, hospital, or medication is also challenging. The latest version of healthcare.gov has a spot for “list of covered drugs” in each plan profile, but in many cases it’s blank. The new site also has clear links to health plans’ provider directories. “Those directories are notoriously out of date, and calling your doctor may not answer the question accurately,” says JoAnn Volk, a senior research fellow at the Center for Health Insurance Reforms at Georgetown University. She recommends people call insurance companies directly to confirm that providers are covered.

Even if your physician is in-network when you sign up, doctors can drop out of plans during the year. Likewise, the list of drugs that are covered, or the amount patients must pay for them, may change. Some states have laws to ensure continuity of coverage, though no federal rules protect consumers if a plan changes midyear. “Eventually I think we’ll see consumer protections in this area, but for the most part they don’t exist now,” says Lynn Quincy, associate director for health reform at Consumers Union.

Another challenge for patients is trying to understand how much they’ll pay for medical care. Premiums are the most visible price tag when people are selecting health plans, but lower-premium plans generally have higher costs when people go to the doctor or hospital, in the form of deductibles, co-pays, and co-insurance. Obamacare covers preventive care without cost-sharing and limits patients’ total out-of-pocket costs to a maximum of $6,600 for an individual or double that for a family policy. That applies to covered services—if a patient goes to a doctor out of network or gets care that the policy doesn’t cover, there’s no limit to how much they might charged.

Even those who understand the mechanics of cost-sharing have a tough time estimating how much a prescription or procedure might cost—assuming it’s not an emergency and you can shop ahead of time. Consumers are largely in the dark about both the prices of medical care and the quality of different providers. While an array of attempts to gauge quality and price exist, patients may not know where to find them or how reliable they are. “We’re not getting good information into their hands in a usable, actionable way,” says Quincy.

Even with those failures, the individual market for health insurance is better for consumers than it was before Obamacare, Quincy says. Health plans are more standardized, making them easier to compare, and insurance carriers can’t deny coverage or charge sick people higher premiums. “There aren’t so many tricks and traps any more,” she says. And insurance companies increasingly see the new marketplaces as attractive places to do business, with 77 health plans joining the exchanges in their second year of operation.

That’s a sign of a functioning market in an industry rife with market failures, where the patients are often ignorant of the true cost of care and removed from decision-making, says Ceci Connolly, managing director of PricewaterhouseCoopers’s Health Research Institute. “We’re turning all that on its head, which I think the right the goal,” she says. “But it’s going to be a rough path to get there.”

For resources to help make you a better health care shopper, click here.

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