Unable to Meet the Deductible or the Doctor

By Abby Goodnough and Robert Pear for the New York Times:

Patricia Wanderlich got insurance through the Affordable Care Act this year, and with good reason: She suffered a brain hemorrhage in 2011, spending weeks in a hospital intensive care unit, and has a second, smaller aneurysm that needs monitoring.

But her new plan has a $6,000 annual deductible, meaning that Ms. Wanderlich, who works part time at a landscaping company outside Chicago, has to pay for most of her medical services up to that amount. She is skipping this year’s brain scan and hoping for the best.


“To spend thousands of dollars just making sure it hasn’t grown?” said Ms. Wanderlich, 61. “I don’t have that money.”

About 7.3 million Americans are enrolled in private coverage through the Affordable Care Act marketplaces, and more than 80 percent qualified for federal subsidies to help with the cost of their monthly premiums. But many are still on the hook for deductibles that can top $5,000 for individuals and $10,000 for families — the trade-off, insurers say, for keeping premiums for the marketplace plans relatively low. The result is that some people — no firm data exists on how many — say they hesitate to use their new insurance because of the high out-of-pocket costs.

Insurers must cover certain preventive services, like immunizations, cholesterol checks and screening for breast and colon cancer, at no cost to the consumer if the provider is in their network. But for other services and items, like prescription drugs, marketplace customers often have to meet their deductible before insurance starts to help.

While high-deductible plans cover most of the costs of severe illnesses and lengthy hospital stays, protecting against catastrophic debt, those plans may compel people to forgo routine care that could prevent bigger, longer-term health issues, according to experts and research.

“They will cause some people to not get care they should get,” Katherine Hempstead, who directs research on health insurance coverage at the Robert Wood Johnson Foundation, said of high-deductible marketplace plans. “Unfortunately, the people who are attracted to the lower premiums tend to be the ones who are going to have the most trouble coming up with all the cost-sharing if in fact they want to use their health insurance.”

Deductibles for the most popular health plans sold through the new marketplaces are higher than those commonly found in employer-sponsored health plans, according to Margaret A. Nowak, the research director of Breakaway Policy Strategies, a health care consulting company. A survey by the Kaiser Family Foundation found that the average deductible for individual coverage in employer-sponsored plans was $1,217 this year.

In comparison, the average deductible for a bronze plan on the exchange — the least expensive coverage — was $5,081 for an individual and $10,386 for a family, according to HealthPocket, a consulting firm. Silver plans, which were the most popular option this year, had average deductibles of $2,907 for an individual and $6,078 for a family.

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Jon R. Gabel, a health economist at NORC, a research organization affiliated with the University of Chicago, said that employer-sponsored plans had lower deductibles, in part, because they provided more generous coverage than the most popular exchange plans. The typical employer-sponsored health plan would qualify as a gold-level policy under the standards of the Affordable Care Act, Mr. Gabel said.

The website for the federal insurance marketplace serving 36 states, HealthCare.gov, strongly encourages consumers to focus on premiums: When consumers search for a plan online, the results are ranked by premium price, with plans offering the lowest premiums listed first.

But insurance plans with lower premiums generally have higher deductibles. Gina Brown, 37, of Nashville, was paying about $155 a month for a Blue Cross Blue Shield of Tennessee plan, after taking account of her subsidy. But her deductible was $4,000, she said, and so she avoided going to the doctor even when she got an ear infection over the summer.

“I attempted to treat it with over-the-counter and homeopathic meds,” she said. “Eventually it went away.”

Ms. Brown recently got a job with health benefits, so she canceled the marketplace plan. Her new insurance has a deductible of $1,000, but primary care visits and prescriptions are not subject to the deductible.

“Now that I know I can go and safely just pay a co-pay,” she said, “it makes me feel better.”

Mark Yuschak, 57, of Jackson, N.J., said he had a silver plan with an annual deductible of $3,000. He discovered its limits in March.

“My wife had an incident, a digestive disorder, and we had to go to the emergency room of a hospital in Freehold, N.J.,” Mr. Yuschak said. “We presented our insurance card and filled out all the forms. They told us, ‘You don’t have a co-payment, you’re free to go.’ ”

Later, though, they received a bill “that could choke a horse,” Mr. Yuschak said — for more than $1,000. “Our insurance wouldn’t cover any of it because we had not met our deductible.”

Carol Payne, a respiratory therapist in Gilbert, Ariz., signed up through HealthCare.gov for a Blue Cross Blue Shield plan with a $6,000 deductible. She pays $91 toward her monthly premium and gets a subsidy of $353 to cover the rest.

The plans she could have chosen with lower deductibles were from insurers that “were not as reputable,” Ms. Payne said. She has used the insurance for preventive care and an emergency room visit after a car accident.

“I’m just doing what I can to keep myself healthy,” she added. “I mean, $6,000 — do they think I’ve just got that under my mattress?”

People with low incomes may qualify for subsidies that reduce their deductibles, co-payments and other out-of-pocket costs. The assistance is available to people with incomes from 100 percent to 250 percent of the poverty level (from $23,550 to $58,875 for a family of four), but only if they choose a silver plan.

Consumers also benefit from a provision of the Affordable Care Act that limits out-of-pocket costs, which include deductibles. The limit this year is $6,350 for an individual and $12,700 for a family plan. But in general, the limits apply only to care provided by doctors and hospitals in a plan’s network and do not cap charges for out-of-network care.

Dr. Rebecca Love, of Moab, Utah, is well on her way to passing that limit. Dr. Love, 63, who has degenerative arthritis and a host of other health problems, pays $422 a month in premiums for a plan that has a deductible of $6,000. But she has already paid more than $6,000 in medical costs this year that did not count toward her deductible because the doctors and hospitals — more than 100 miles away in Grand Junction, Colo. — were not in her network.

To see certain specialists in her network, Dr. Love said, she would have had to travel to Salt Lake City, which is much farther away and requires driving through a treacherous mountain pass.

“Medical care costs too much and health insurance as it stands doesn’t address this,” she said. “What have we become?”

Ms. Wanderlich, who had suffered the brain hemorrhage, was even avoiding preventive care until last month, when she had to get a prescription renewed and her doctor’s office required her to be seen first. Grudgingly, she went for an annual physical exam on Sept. 12. She was relieved to learn that she owed only $30 for the visit; the provider billed her insurer more than $1,200.

When the next open enrollment period begins on Nov. 15, Ms. Wanderlich said, she will probably switch to a plan with a narrower network of doctors and a smaller deductible. It will probably mean losing her specialists, she said, but at this point she is resigned.

“A $6,000 deductible — that’s just staggering,” she said. “I never thought I’d say this, but how many minutes until I get Medicare?”


  1. Ron Anthony on October 29, 2014 at 3:11 pm

    The cap for the out of pocket expenses did not go into effect in 2014 as it was originally supposed to. If it goes into effect in 2015 as it is now supposed to, it will have to add to insurance company costs and of course be added to premiums and deductibles. This will make it all worse as will other aspects of Obamacare that are still in the pipeline like the employer mandate and tax on “Cadillac Insurance” plans.

  2. Allan Tweddle on October 29, 2014 at 5:54 pm

    The only sensible and fair solution is to get the insurance companies the hell out of healthcare. Healthcare is not a market it is a human right. Why are we still feeding the greed, the profits and huge multimillion at salaries of the healthcare insurance companies when all the other western countries have developed plans and had them in place for decades that cost less than half of what we pay for healthcare with equal or better results.

    Being from Canada originally, I keep asking Americans for the last 30 years to please tell me what the insurance companies contribute to health care, and I have never had any rational answer whatsoever.

    • girlcousin on October 29, 2014 at 9:23 pm

      You got that right! We couldn’t afford any plans on the Health Care exchange–$1050 for the crappiest of the crappy bronze anthem plan, but happily, we get no help sending my daughter to college, so we can deduct the $5000 off our AGI thus putting us UNDER the 400% of poverty level so we can limit our premiums to 9.5 of our AGI. Even though this is REALLY expensive, it is better than the 16% of AGI we were supposed to shell out for health care it almost seems reasonable. But, yeah, if your employer doesn’t pay it, you are screwed. BTW–filed for an exemption, still waiting to hear back from HHS. Bottom line, none of us can afford insurance!

      • Pete Piper on November 23, 2014 at 5:55 am

        girlcousin, don’t know your age or where you live or if you are insuring yourself or your whole family. Still, $1050 seems awful high for unsubsidized ACA insurance. A 45 year old couple in Texas pays $650 (unsubsidized) for a silver plan, for example. A good place to estimate premiums (including subsidized premiums) is at the Kaiser Family Foundation website’s calculator. If you live in a state that expanded Medicaid, a family can get free insurance if their income is less than $30,000.

  3. Sue on October 29, 2014 at 8:05 pm

    I keep hoping that we get non-profit single payer health insurance in this country and sooner rather than later.

  4. Konnie Garrido on October 29, 2014 at 9:37 pm

    While this article eloquently describes the current conundrum of excessive deductibles preventing an insured from accessing healthcare, it still doesn’t address the real problem in our country – too many Americans are still being lulled into a sense of “I have employer-based insurance so at least I’m okay” security. As long as the majority of Americans continue to receive reasonably palatable insurance benefits through their employers, the rest of us – the vast minority – are left out to dry. There simply aren’t enough of “us” to push through single-payer protection, though I am so grateful to everyone who is trying, however many, many years it may take to achieve. Employer-based health insurance may be the biggest foe of single payer…….

  5. teri on October 30, 2014 at 6:11 am

    From the article: “About 7.3 million Americans are enrolled in private coverage through the Affordable Care Act marketplaces” . I thought the idea was that everyone would have insurance. Surely the rest of the US, population roughly 330 million, does not have private or employer-provided insurance. Even if you assume we are only talking about the adult population, with children being covered under their parent’s plan, there would still be over 90 million Americans who should be covered by insurance policies per the ACA mandate. Are we really to believe that these 83 million adults NOT on the exchanges have private insurance?

    How many people still have no insurance coverage whatsoever? Anyone know?

    I would also like to say in passing that the plans on the ACA suck. I am taking a pay cut to stay on my employer’s plan because the marketplace plans are unacceptably awful. What makes me grit my teeth is the fact that in a sensible nation, there would not be for-profit insurance companies at all. When I first entered the workforce back in the 70’s, most insurance companies were non-profit. Now all we have is a cartel of companies we are forced to buy from. We have lost our minds.

    • Pete Piper on November 23, 2014 at 5:44 am

      Betty, don’t know what you mean by a “pay out” to stay on your employer’s plan. If you are eligible for employee group insurance, you are NOT eligible for ACA insurance.

      The ACA has over 7 million enrollees through the exchanges and another 7 million through the states that expanded Medicaid. Also, around 30 million seniors benefit from the elimination of the Medicare Part D “doughnut hole”. And 3 million benefit from being able to stay on their parent’s plan. The number of uninsured has been reduced by 12 million. It would have been reduced by 20 million if the Republican controlled states expanded Medicaid.

      The ACA does not affect Medicare (except for $3000 in potential prescription drug savings) or employee based insurance.

      Already 17,000 lives a year are being saved by those now having insurance and 20,000 medical cost bankruptcies each year are eliminated. The stories of $6000 deductibles are false since max yearly out of pocket is $6500 per year. All plans cover the regular checkups and medication proved to improve health with no deductible. Contraception is free, too.

      • Terrie on November 26, 2014 at 8:19 am

        Well one can check the numbers and see yes people are getting stuck paying large and who is going to pay for the coverage for the ones that cant it has to come from someone ? It takes from the ones that pay to provide for the ones that cant and we can expected its going to rise read the 923 pages of Obamacare you really don’t have a clue what the $$$ Gruber said it we have been lied to
        no surprise to the ones that took time to read the bill.If you want to talk know what your talking about Repeaters are just that Repeating the lie !!

  6. Betty Fackler on November 18, 2014 at 12:10 am

    The insurance companies are also putting small businesses in peril. Hawaii law requires employers to pay more than 90% of the insurance cost for all employees working over 20 hrs/wk (federal requirement is 30 hrs/wk). Premiums with our non-profit BC/BS are now up to $800.00/month per eligible employee for a required “gold or platinum” plan equivalent on the healthcare exchanges. No tax credit for 2014 because insurance had to be purchased from the “exchange” and it was not working well enough to get signed up. New enrollment on the “exchange” now only offers a single HMO insurance company, as the non-profit with PPO withdrew. $3200.00/month is a big bill to cover 4 employees, but there is no choice. Employers are not able to carry these greedy insurance companies on our backs any longer either. I love my employees and will keep them insured as long as we can keep our little business running.

  7. bill shaver on December 18, 2014 at 3:54 am

    single payer the way to go be it at the fed or state level…cover all costs on the tax pool they collect, have the fed or stste level buy a policy for all, unilaterally cover all…end the problems of duplicty & triplicate billing …uniform billing to the fed or state