Instead, Carol called the office of Steve McCarter, her representative in the state House of Representatives. “They told me to fill out a complaint form and to check out the federal exchanges in October,” she recalled. Her next stop: the office of Patrick Meehan, her congressional representative. There a staffer informed Carol that a complaint about high premiums was a legislative issue, and the office would call her back. By the end of May, nobody had called.
Carol feared a runaround and she got one. But Aetna’s hefty premium increase is not simply a consumer’s complaint. It is a big dollars-and-cents issue for thousands of families like hers that have seen their premiums climb into the stratosphere over the past decade—a problem unlikely to quickly disappear under Obamacare. A look at her current predicament may help illuminate the kinds of choices she and many others face in coming months.
Carol had chosen her HMO 30 policy because it appeared to be the cheaper option at the time. It covers her and two adult children in their early 20s, who stayed on her policy after college, thanks to an Obamacare provision that lets young adults remain on their parents’ plan until age 26. (Her husband, 59, a former railroad worker, is disabled because of a job-related injury. He gets a pension from the Railroad Retirement Board and health coverage from Medicare.) Carol earns about $20,000 a year as a freelance proofreader. Before premiums got so expensive, she had coverage from what is called a preferred provider organization, a PPO. “I loved it,” she said.
Who wouldn’t? She could go to any doctor, and the out-of pocket costs and the premiums were reasonable. The PPO got too expensive, so she chose a new plan called the HMO 15, a managed-care policy with restrictions on which healthcare providers she could use, but with reasonable copays. Premium increases continued to pile up, however, and she switched again—to the HMO 30 plan, with slightly lower premiums but much higher copays and more cost-sharing. She didn’t shop for insurance from other companies. “It was so hard to compare plans,” she said. “I just gave up.”
Comparing plans is very hard—even for people like me who are supposed to understand them. Comparing even a few of the benefits—all the while not knowing which illnesses you or your family member may face in the next year—requires a person to calculate risks and make tradeoffs. That’s a tough exercise that requires an understanding of how insurers price their products, and what the fine print means—like the difference between coinsurance and copayments and how deductibles vary depending on where you receive care. Insurance companies tend to mix and match between various costs for various kinds of services, a little more for this, a little less for that, making apples-to-apples comparisons difficult.
For example, Carol’s HMO 15 plan required a $15 copay—a set amount for a service—for a CT scan or an MRI done as an outpatient, a $15 copay for outpatient X-rays, and blood work, and a $15 copay for urgent care. With her HMO 30, the premiums were slightly cheaper but the copayments shot way up—$250 for CT scans and MRIs, $50 for blood work and X-rays, and $200 for a visit to an urgent-care center. And while her old plan required a $15 copayment for the facility fee at an outpatient surgical-care center, the HMO 30 requires a $550 copay, an amount Carol found challenging. “I was supposed to get an endoscopy ,” she told me. “I cancelled it.”
She did make an appointment for a gallbladder-function scan because the copayment was only $50. “The average person does not understand why certain tests require a huge copay, and others don’t,” she said. Drug coverage was different, too. In short, health insurers are pushing consumers toward choices that may be best for the insurer’s bottom line.