HAVING HEALTH INSURANCE IS NOT THE SAME AS HAVING HEALTH CARE

I’m puzzled by the name of the Affordable Care Act (ACA). I’m one of a large body of newly-senior citizens who qualify for Medicare at age 65. But, as this is only my 64th year on the planet, I’m also in my last year of government mandated purchase of health insurance as required by the ACA. Complying with the purchase mandate, however, doesn’t really translate to having Affordable Care, because I certainly don’t.

My wife and I will both be turning 64 this year. We are counting the days, literally, until our decades of tithing into Medicare begins its payback. We both qualify for full coverage at 65, but until then we are stuffed wallet-first into that zone where we are basically paying a giant chunk of our small income to fund other people’s health care, and virtually none of our own. This is a classic definition of redistribution of wealth, but in our cases it isn’t so much redistribution of wealth as it is redistribution of paycheck. We work, and each month we funnel a big share of our modest earnings into a health insurance exchange so that others, who typically don’t work, can have cheap or free coverage. And somehow, through the law, we end up with virtually no coverage.

We both work full time, and although we don’t make much, we make enough to disqualify us from any federal subsidy of our insurance costs. Our employer, like many small business employers, doesn’t pay for any of our health insurance, they simply can’t afford to and remain competitive. And at our age, even though we are in excellent health, we are brushing up against the very tall ceiling of the cost structure for individual health insurance. When our income is added to a small pension from a previous career, we make enough to be comfortable, but not enough to sock away any appreciable savings. So we live comfortably as long as a disaster doesn’t strike. Because we can’t afford anything better, we chose to purchase a Bronze Plan through the state exchange. Affordable, in this case, is equivalent to Catastrophic Coverage. It provides us with minimal no-cost preventative care but has a whopping $6,000 (each) deductible for everything else. And after the deductible is satisfied (and most of our savings is gone), we are still on the hook for 40% (up to $6,350) of the next $15,875 in expenses. If a catastrophe strikes, even a moderate one, we will be well into bankruptcy before full insurance coverage takes over.

So, back to my puzzlement, why is Obamacare called the Affordable Care Act, and not the Mandatory Insurance Act? We comply with the law, but still have no effective health care coverage, and especially not affordable coverage. For even a modest hospital stay, we would be bankrupted even with our insurance. So why, then, should we carry the insurance at all? Our coverage provides for, at no additional cost, an annual physical exam for each of us, a mammogram for my wife, and flu shots. Even at the inflated prices that our health care provider charges to an individual out-of-pocket patient (which are 68% or more discounted for our insurance carrier), we would pay less than $1,600 per year for those things that are covered by our policy. The following diagram shows what we would pay for progressively more health care (there is one column for each of us).

As a reference point, here are some claims made by our health care provider, Evergreen Health, and paid by our insurance carrier, Ambetter Coordinated Care:

From a health care needs standpoint, if we assume the best scenario (no health events during the year), we are out a total of $10,960 for our policy, but get about $1,600 in medical services for that. Our insurance carrier, by the way, will pay only about $200 for those services for me, and about $335 for my wife. That gives them a tidy profit of well over $10,000. The government rationale is that this profit can help to soothe the costs of covering others who pay far less for their insurance, or nothing at all. I’m still waiting to see any facts or science to support that rationale.

If we assume a more serious scenario, an injury or illness requiring a minimal hospitalization, we will probably be out-of-pocket another $5,000-$6,000 for a total of $16,000 or so. Our insurance carrier has, by now, still only paid about $550 for services since we absorbed all of the costs in our policy deductible. Their tidy profit is still intact.

God forbid we have a much more severe scenario, a major injury or illness requiring a lengthy hospitalization. We will easily blow through the deductible, and then easily surpass the next $15,875 of 40% coinsurance expenses before full coverage finally, mercifully, kicks in. We will, unfortunately, already have exhausted our modest savings, shoveling those dollars into the total out-of-pocket obligation of $23,310 (insurance policy, plus $6,000 deductible, plus $6,350 maximum out-of-pocket during coinsurance). This not-so-unlikely scenario puts us out of savings, deeply in debt, out of work, and in the hospital. Thank God at least one of us is being fed, even if it’s hospital food. That assumes, of course, that it isn’t both of us in the hospital, and we haven’t double-bankrupted ourselves.

How is this Affordable Care?