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The Frustrating Thing(s) About the US Health Insurance Marketplace - Part 3

This is part 3 of a 3 part series. Click to read Part 1 and Part 2 for background on the story.

In parts 1 and 2, my friend Eva tries and eventually succeeds in getting an appointment so she can get treated for what turns out to be severe laryngitis and walking pneumonia, and how the market-based insurance system foils her attempts.


At the end of the last post, I asked the question "What would have happened to Eva if I (or someone else with health system insider knowledge) hadn't been there to help her get connected to people who could see her that day?

Scenario 1: She gets frustrated with not being able to find a primary care practice who can see her that day and so decides to go to the local public hospital emergency department (ED) --because they will take her insurance.  She goes to the ED and spends hours waiting to be seen because her case is considered non-urgent.  Eventually she is seen in the overcrowded ED and gets sent home in the middle of the night (or next morning even) with the same prescription.  It cost her insurance $500 as soon as she registered as a patient in the ED and her copay for an ED visit is $50.

If she'd been seen in primary care, it would have cost the insurance company $125 (by local market standards) and her copay would have been $25.

Scenario 2: Despite being young and healthy (she's 35), walking pneumonia is nothing to mess with and it can get worse.  Since she wouldn't have known she had it, she probably would have put off trying to get seen because it was too complicated.  Knowing full well how long she'd wait in the ED (public or private) and because urgent care wasn't an option because they didn't take her insurance either, trying to ride out the illness using over the counter prescriptions was the next option.

Walking pneumonia can turn into regular pneumonia and if it gets really bad, she could have ended up hospitalized. Even if the infection didn't end up hospitalizing her, she would have hit a point where she would have needed to go be seen by someone.  People delay seeking care all the time for lots of reasons that often defy rational thinking, and in her case her rationale choice might have been to avoid paying for the most expensive option.

In addition, since trying to find someone who would take her insurance would have been even more difficult if she was feeling awful and still wanted to avoid the ED, then urgent care and paying out of pocket becomes her only option.  Sure, she could charge it to a credit card, but then the illness would cost her money for months ahead as she pays it and the interest off.  Remember: She's only consulting at the moment and her income isn't regular.  It all becomes an unnecessarily complicated mess.

If all providers were required to take all insurance, she would have had no problem getting seen without the help of someone like me.

If she lived in a country with a single payor system, she might have had to wait but she still would have been seen the same day.

If Eva was poor and/or less educated, the scenario would have been far worse and more costly.  Poverty is costly to your health.

What's the take home message?

From this story, you can see in the system inefficiencies that are private sector driven that the incentives are not designed to benefit the consumer.  The insurance companies benefit in one way by consumers not using their insurance.  They can work off of the 23-35% administrative overhead built into private insurance costs because people skip care or they deny access. That helps their bottom line and ensures that executives still get their six figure bonuses (yes, really, many do).

Physicians benefit because they can choose to accept the insurances that reimburse at the highest rates or require the least amount of paperwork. If the state where they practice or the insurance plan doesn't allow nurse practitioners to be designated as primary care providers, they have less competition for the patient market and incomes (supposedly) are higher.

So that's the "perks" of a market driven system.  There's choice!  Sort of.  There's more efficiency! Not so much.

And it is important to note that these same inefficiencies existed PRIOR to ACA implementation.

Overall, it is by far better to have health insurance as the annually increasing ACA enrollments and dropping uninsured rates demonstrate.

But even if you have insurance, it shouldn't be so hard to access the system --especially now.

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