Thoughts on the Affordable Care Act from Someone Who Works With It Daily

This is a little off topic but I also felt the need to share some thoughts as it is a HOT topic these days.

As a current Health Coverage Guide with Connect for Health Colorado, Colorado’s state exchange and marketplace for the Affordable Care Act, and a previously licensed insurance agent prior to the law’s start, I have some insight into what many in my area feel needs to be changed for the healthcare issue. Along with this current experience, I also worked in law offices and studied medicine in school.

First, healthcare needs to be affordable. There is no denying that, and I believe the theory of the Affordable Care Act is 100% right. However, portions of the law and the burden on individuals and families far outweigh the pros I’ve witnessed in the law. The Affordable Care Act set out to make insurance accessible and affordable for everyone, but most of the people I meet with cannot afford the high premiums or fines associated with it, nor do they see the benefit in high deductibles. I am included in this.

Per the Affordable Care Act, my employer must offer health insurance as they employ more than 50 full time employees at the hospital in my very rural town in Colorado. Therefore, that means I cannot obtain any financial assistance through insurance affordability programs and must pay full premium costs. Also, the law states that if my dependents are also offered insurance like my husband is, we must pay full cost for him to be insured as well or face the penalty at the end of the year. My husband is currently not working for any employer as he starts his own business with photography after leaving nursing because he grew ill and now has recovered. Colorado state insurance law requires that employers only pay 50% of the cost for employee-only coverage. It does not state anything in regards to dependents. As my health insurance premiums for only myself are not more than 9.5% of our household income, I am required by the Affordable Care Act to pay full price for my husband and the full 50% of mine as the employee. Therefore, we are paying approximately $500 per month to have health insurance. This is another rent payment in our community or even two vehicle payments we could be making. If we opt to not take the insurance, we will need to pay $1,395 for a penalty at tax time when our return is usually only $400. This causes an enormous problem for us.

It’s been pointed out to me that why can someone only making $11 per hour fully support their family of 3 while I have a harder time for a 2 person household making a bit more. I want to explain to him that that person probably qualifies for Medicaid and other benefits. I obtained a degree in psychology and yet I am barely making it from check to check all because I am now over the Medicaid cutoff at $21,307 for a household of 2. So, in trying to better my life, it seems I’ve hindered myself. However, I am not a person who is content to work less and collect welfare. I believe in creating new opportunities and growing my husband’s new business as well. It simply feels that the way the system is established now, we are blocked from this opportunity routinely. People tell us constantly my husband needs to quit his dream of being a business owner with his photography and that we must both work 40 hours a week.

Also, the customers for the Affordable Care Act who visit me share repeatedly how they hate the requirement to pay for insurance that includes coverages they will never use. Many in our area are near retirement or at retirement. They do not see the need to pay for maternity & newborn care or pediatric dental. A 63-year-old confirmed bachelor with no children was angry in my office when I shared he was paying for that coverage. Even on Connect for Health Colorado’s site we must explain that if the carrier does not have pediatric dental built into their plans, we must have the customer purchase a separate pediatric dental policy to meet the requirements of the law, even if they have no one in the home who can use the coverage.

Like I mentioned before, I am a formerly licensed insurance agent. Why can’t health insurance be like auto insurance where we pick and choose what coverage we want or need? Someone with no child would choose to uncheck the box for pediatric dental. An older couple could choose to uncheck maternity & newborn care. This could lower the individual and family insurance premiums alone. If anything needs to be mandatory, make that emergency and hospitalization coverage. The insurance companies can still be required to cover all the other types, but the consumer chooses what coverages are included on his or her plan.

I firmly agree about creating interstate plans and removing state boundaries when it comes to insurance coverage. Our town in Colorado is only 17 miles from the nearest town in New Mexico. Many of our residents choose coverage in that town too. Because of insurance being limited to just our state, they are not covered for any procedures unless emergency. In one instance as an example a woman was diagnosed with cancer. Her doctor told her the best treatment was at the Cancer Institute in Houston, Texas. Since her policy was by an insurer limited to Colorado only, this customer could not do so without paying the cost entirely from her own pocket.

Another issue I see in the marketplace is that insurers have discontinued PPO plans in our area. Therefore, individuals are limited to just our state networks and cannot see a specialist without a referral from their primary care doctor. If one desires a second opinion he or she must ask the current primary care doctor for permission to do so. Should they opt to change their primary care provider, insurance companies now make them wait until after the first of the next month. Isn’t this preventing a patient the right to a second opinion? In many cases, a second opinion cannot wait.

On another front, the cost of healthcare itself is astronomical. When my husband was working in nursing and ordering supplies he noticed the price of a band-aid that probably costs ten cents at most to manufacture cost the providers $5. In turn, the provider then charges $10 to cover the cost of the staff meeting with the patient to put the band-aid on them. As someone who studied medicine for a while and then became an insurance agent, I understand the cycle that exists. Providers raised their costs to discourage the consumers who consistently go to the providers for even just the sniffles instead of real needs and to cover their costs. The insurance companies now had a bigger expense and raised insurance rates also, raising our premiums. When we also remove pre-existing conditions which I think has been a great benefit to the law, we increase what the insurance companies must pay again as they no longer have the luxury to pick and choose who they will cover. That, in turn, makes them raise our premiums even more. While I understand they need to cover their costs, I also don’t understand why a CEO of an insurance provider can take home a $35 million salary each year as we, the Americans required to have health insurance, can hardly afford to pay our regular daily life bills because of high premiums.

Despite this, I do believe the removal of pre-existing conditions is something we must maintain in the new law. I witnessed firsthand as an insurance agent how this helped individuals. A man retired at 55 years of age from his job. He used COBRA for the 18-month period and then decided he needed to purchase new, individual insurance. We looked up his rates and filled out applications. All of them were denied because based on the man’s age he was at risk for heart disease and potentially a heart attack he was told. The man was still only 57 and could not enroll in Medicare for several more years. In that instance, he ended up paying nearly double the initial premium with one carrier until he could obtain Medicare. Without pre-existing conditions this man never would have faced these obstacles. Health insurance is a necessity for those with health issues. That’s why I am glad that pre-existing conditions no longer exist in our plans and it should stay that way.

I wish that more states could follow Colorado’s example. We offer a discount plan to residents of our state called the Colorado Indigent Care Program. I assist people with this program every day at work also. It is not actual health insurance. Therefore, the people on it are not covered to meet the Affordable Care Act. If they do have regular insurance it will work almost like a secondary insurance to create a rate category for the ones who sign up based on their income. The income limits are 250% of the Federal Poverty Level and one cannot have Medicaid either. The rates then provide them with set co-pays for certain crucial services, even backdating 90 days prior to their application date. Those who have no insurance have opted for this to help with medical bills should they require them. This at least helps individuals with high medical costs obtain some type of assistance and can even assist with high premium, lower cost-sharing plans in the marketplace. A customer could decide to purchase a plan with lower premiums but a higher deductible, and then sign up for the Indigent Care Program to ease their out of pocket costs for services.

Just ramblings of real life experiences from someone in the trenches.

Thank you for listening and all the best!

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