ObamaCare Roundup: Random Rates and Narrow Networks

By Lambert Strether of Corrente

In yesterday’s roundup, we pointed out that the administration has left about 3.7 million Medicaid applicants or beneficiaries under ObamaCare in limbo with paperwork problems. That’s third world stuff. It’s unconscionable. There’s no excuse for it. And it’s all the more a saddening indicator of the general demoralization and crapification of American life that pointing such things out produces ennui or worse, excuse making, instead of burning outrage at the way a government that’s supposed to be of the people, by the people, for the people actually treats its citizens, especially when they are suffering or in need.

That said, I want to look at two emergent and continuing problems with ObamaCare. First, rates that vary randomly by jurisdiction; and second, narrow networks for both doctors and pharmaceutical formularies. (These problems have long been known to NC readers; see here, here, here, and here.)

ObamaCare and Random Rates

That insurance rates would vary wildly by jurisdiction was known before launch:

Consumers [sic] shopping in the new health insurance marketplaces will face a bewildering array of competing plans in some counties and sparse options in other places, with people in some areas of the country having to pay much more for the identical level of coverage than consumers elsewhere.

A Kaiser Health News analysis of the 1,923 plans being sold on federally run online marketplaces found wide variations of price and availability. For instance, Cigna is offering 50-year-olds one of its midlevel plans for $614 if they live in Flagstaff, Ariz. That same plan, contracting with different hospitals and doctors, will cost $428 in Phoenix and just $395 in Nashville.

(Here again, NC readers could see this one coming.) And the variations did indeed happen after launch. For example, in Michigan:

Rates in these rural counties are among the highest in the state, according to analysis by the Ann Arbor-based Center for Healthcare Research & Transformation (CHRT), a nonprofit partnership between the University of Michigan and Blue Cross Blue Shield of Michigan.

The least expensive basic plan for a 40-year-old couple with two children costs $761 in Delta County, compared with $462 a month for a comparable plan in Kent County, $560 in Washtenaw County and $566 in Ingham County. While Delta County offered just five insurance plans with one insurer, Kent County had four insurers and 33 plans, Ingham County five insurers and 39 plans and Washtenaw County five insurers and 40 plans.

Again, I think this is unconscionable. Where’s the justice in a citizen who lives on one side of the county line paying more for health insurance — and making life, or even life and death, decisions based on how much they have to pay — and a citizen on the other side paying less? None, that I can see. Well, to be fair, costs — and hence insurance company profit margins — may be different in the two counties. But all that says is that we need a single payer system to introduce a baseline of basic fairness. Social Security benefits don’t vary by the county, so why should health care costs?

ObamaCare and Narrow Networks

Once again, ObamaCare mandates that you walk into a minefield that has no signage or worse, deceptive signage. Whoopsie! For those who came in late, here’s a definition of a narrow network:

Narrow networks are health insurance plans that place limits on the doctors and hospitals available to their subscribers.

They tend to do this in two ways, the first — and most obvious — by simply not paying for trips to doctors that aren’t in their restricted network. The second version, a bit more nuanced, typically has health insurance plans charging higher co-payments to go see a doctor who isn’t in the “top tier.” In this case, you can go out-of-network — but will have to pay a higher price in order to do so.

They do this, of course, to keep costs low (and margins high):

As Americans have begun shopping for health plans on the insurance exchanges, they are discovering that insurers are restricting their choice of doctors and hospitals in order to keep costs low, and that many of the plans exclude top-rated hospitals.

(From the consumer citizen perspective, narrow networks are just the latest scheme by health insurance companies profit by denying you care; their business model has not changed, and how could it? And as a side note, if you’re checking with your insurance company about your coverage over the phone, be sure to record the conversation so you have a record, because — whoopsie! — they’ll flat out lie to you.)

Never mind Obama lying about keeping your doctor and your plan; narrow networks blow that away. What’s in and out of network really matters, because — whoopsie! — you can be on the hook for everything if you go out of network. But as Kevin Drum explains, nobody’s looking out for you but you, and in the nature of the case, you’re stressed, sick or injured, possibly even disoriented, and prone to error. Error that’s profitable for the insurance companies, naturally.

[Narrow networks have] been a growing problem with private insurance plans for years…. [I]t gets worse with Obamacare in some states because of the narrow networks supported by nearly all ACA insurers. For example, [one reader] confirmed to me that he had a Blue Shield plan, but that’s not the whole story. “The blood lab in question is in network for Blue Shield, but not for Blue Shield CoveredCA [whoopsie!] plans, as per everyone I’ve spoken to about it.” …

[I]’s really hard to be alert enough all the time to avoid this. You have to remember to ask every time. You have to ask every doctor, and you have to ask for every lab test. And most doctors don’t know, and don’t really want to be bothered finding out. So you have to be very, very persistent.

And most of us aren’t very, very persistent. Especially if, say, we’re in an ER worried that chest pains [whoopsie!] might be an indication of an oncoming heart attack.

How big a deal is this? I don’t have any way of knowing.

Not only does Drum have no way of knowing, I don’t think ObamaCare itself has any way of knowing; everything is siloed by insurer. They have no reason to make themselves look bad, and there’s no way to aggregate the data for problems like this for ObamaCare as a whole.

But [the reader] is certainly right that it’s the kind of thing that can give Obamacare a bad name if it happens often enough.

And not only “give ObamaCare a bad name,” hilariously the no-doubt-insured Drum’s central concern. No, cost you — whoopsie! — thousands and thousands of dollars!

So, let’s look at narrow networks from two angles: Doctors, and drugs.


A narrow network, by definition, means that there’s a good chance that your doctor won’t be part of your plan. Now, you’d think you could at least check the ObamaCare website to be sure, but of course that’s a #FAIL. In California:

Many consumers have also encountered difficulty finding a doctor who accepts their new coverage, as well as frustration with inaccurate provider lists, according to the California Department of Managed Health Care.

Still in California:

A month into the most sweeping changes to healthcare in half a century, people are having trouble finding doctors at all, getting faulty information on which ones are covered and receiving little help from insurers swamped by new business.

And in Missouri, the insurance companies are getting sued for — I hope you’re sitting down for this — lying about how narrow their networks actually are:

An Overland Park woman is suing Blue Cross and Blue Shield of Kansas City, claiming the company intentionally misled consumers about which physicians they could visit through the company’s Affordable Care Act insurance plans.

BCBSKC is one of two companies [Yay! A duopoly!] offering health insurance plans on the ACA exchanges in Kansas.

Debra Simon, in a petition filed in Jackson County District Court, alleges the company marketed its plans as including a specific network of providers. Simon said she checked with Blue Cross to ensure those doctors would be covered prior to purchasing the policy, “and the Blue Cross website indeed displayed the names of the doctors.”

But after she and her family sought care with those providers, she said she was billed for seeing out-of-network doctors.

“Blue Cross’s practices were at best deceptive and unfair, and at worst constituted a deliberate ‘bait and switch’ aimed at attracting greater amounts of customers and insurance revenues,” the petition said. …

The lawsuit was filed as a class action including any BCBSKC policyholders who purchased a plan with fewer in-network providers than was advertised to them. It includes violations of the Missouri Merchandising Practice Act as well as unjust enrichment.

Heck, the entire health insurance industry is a case of “unjust enrichment,” so far as I’m concerned.


From doctors, we pass on to drugs, or, as we like to call them, formularies. First, the same logic applies with formularies as it does with doctors:

The challenge for consumers is that most of the plans have “closed” formularies where non-formulary drugs aren’t covered. Moreover, the cap on out of pocket spending only applies to costs incurred on drugs included on a plan’s formulary. That means that patients could be saddled with the full cost [whoopsie!] of many of these drugs, with no limits on that spending.

So, already we’re in a minefield where we don’t really know what’s covered, and could be on the hook for a really expensive treatment while thinking we’re covered. Second, the plans are just as transparent about drugs as they are about doctors; that is, they’re completely obfuscated:

Consumers who regularly take medication will need to examine their Obamacare plan options carefully. Even before considering cost-sharing rates, the consumer must confirm that their drugs are covered by the health plan. Uncovered drugs are not subject to any limitations on annual out-of-pocket costs. The Affordable Care Act requires only one drug per category and class be covered within a health plan formulary, though the benchmark plan chosen the consumer’s state can increase that number on a per category/class basis. Depending on the state, the minimum number of drugs to be covered by the prescription drug benefit varies from 485 medications to 1,070 medications. Additionally, a particular drug’s tier assignment to “preferred brand name drug,” “non-preferred brand name drug,” and “specialty drug” is left to the discretion of the health plan. Consequently, a drug that is classified as a “preferred brand name drug” in one plan may be a more expensive “non-preferred brand name drug” in a different plan. All of these factors suggest that consumers should do their homework prior to enrolling in a health plan.

So, again there’s no signage in the minefield. This applies to cancer patients in particular:

A recent analysis by Skopec and Sloan looked at the availability of 14 cancer drugs in 62 Obamacare plans offered in five states and the District of Columbia. They found that coverage for those drugs was “fairly comprehensive across plans.”

“We found, however, that cancer patients would face a difficult, and in some cases impossible, task in making apples-to-apples comparison of health plans based on drug coverage,” Sloan and Skopec wrote.

That’s because, among other things, there is no consistency in how plans provide direct links to their drug formularies. Some plans may even lack a comprehensive list of the covered drugs, and the formularies are not organized in the same way, the analysis found.

“The transparency issue is significant, because a person with cancer needs to be able to know that the drugs that they’re taking are on their formulary,” Sloan said.

While Obamacare plans cover more drugs for more people than in the past, not everything is covered. If drugs aren’t included in a formulary, but you need them, “then you’re on your own” in terms of paying for the medication, said Kaiser’s Pollitz.

Third, and even worse, the insurance companies are gaming the formularies to reject patients with pre-existing conditions. In particular, AIDS patients:

Advocacy groups are accusing four health insurers in Florida of violating federal ObamaCare rules by discriminating against people with HIV and AIDS.

The National Health Law Program and The AIDS Institute have filed a complaint against CoventryOne, Cigna, Humana and Preferred Medical in Florida with the Office of Civil Rights at the Department of Health and Human Services alleging that their ObamaCare plans are overcharging for treatments.

According to the advocacy groups, analysis of prescription drug formularies and cost structure for all silver-level Qualified Health Plans in Florida — one of the options under ObamaCare — found the four insurance providers charged inordinately high copayments and co-insurance for drugs used to treat HIV and AIDS.

“When you put up roadblocks to assessing life saving medications through these high out of pocket costs and prior authorizations people with HIV are more likely to miss doses, experience gaps in treatment and go off treatment altogether,” said Carl Schmid, deputy executive director at The AIDS Institute. “As a result patients can develop drug resistance, become sick and even die.”

Fourth, there’s no reason to think the insurance companies won’t try the same trick for all chronically ill patients:

An ObamaCare Silver policy must pay 70 percent of expected medical costs, while covering 100 percent of “preventive care” (as defined by the federal government). However, the plan is designed for the average patient. So, it is easy for a health plan to design a plan that imposes very high medical maintenance costs on very sick, chronically ill people. High co-payments or co-insurance for prescriptions is one obvious method.

Which in fact they are doing:

The Avalere study examined 123 formularies from silver-level exchange plans — the benchmark plan that will generally pay 70 percent of covered medical expenses, leaving the consumer responsible for 30 percent – and found that a fifth of them required cost sharing of 40 percent or more for certain classes of specialty drugs used to treat HIV/AIDS, multiple sclerosis, bipolar disorder, cancer and other illnesses. Avalere also concluded that 60 percent of silver plan formularies placed all medications for multiple sclerosis, Crohn’s disease, cancer and other illnesses in the plan’s highest formulary tier. That means patients who need these medicines would face the highest coinsurance percentage.

I seem to recall that one of the big selling points for ObamaCare was that people with pre-existing conditions would be covered. But here we see how the insurance companies are gaming formularies to prevent that. (As with doctors, it’s not clear how data would even be gathered to find out how widespread the problem is; but perhaps patient advocacy groups can help. To be fair, they’re only doing that to AIDs patients, and people with MS, bipolar disorder, or dancer. So there’s that. If only there were a way to keep pharmaceutical costs low by giving the pharmaceutical buyer some leverage!

* * *

Again let me issue my ritual disclaimer that of course ObamaCare will help some people; a program of that scale could hardly help doing so. My beef is that ObamaCare does not help all people, equally. It’s not fair that the care you get should vary randomly by jurisdiction, or whether you make it through the random minefield of picking an ObamaCare plan and actually getting care without any whoopsies.

NOTE A pleasant example of Orwellian language:

The directors see low health insurance literacy, particularly among the previously uninsured, as a hurdle. For example, they may not expect their out-of-pocket costs to be as high as they turn out to be, especially under the high cost-sharing design in many Affordable Care Act health plans.

“Health insurance literacy.” Translation: “How and why it’s OK for health insurers to sell you a crapified product.”

“We have an education challenge of what it means to be an informed consumer of an insurance product,” Lee said. “We don’t have many good models out there.”

“Health insurance literacy.” “Education challenge.” “Informed consumer.” “Good models.” You can tell from the smarmy language of faux concern that you’re hearing from a fully paid-up member of the Democratic nomenklatura, and indeed that’s Peter Lee of Covered California. I bet you anything if you let him maunder on, he’d want to have a “conversation” about “innovative” policy. Oh, and you don’t have any good models for being an informed consumer of a defective product for the same reason you don’t have any good models for feeding your tapeworm instead of eliminating it.

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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.


  1. Jim Haygood

    ‘Health insurance literacy’ … kind of like ‘Star Trek literacy,’ perhaps. If you want to attend the fan convention, it’s best to be conversant with every episode. But it’s not essential knowledge for lay people.

    This is the inside-out logic of the entrenched bureaucrat who views ‘consumers’ as being obliged to adapt themselves to his organization’s dispensations, rather than vice versa. But that’s the nature of any oligopoly — errr, ‘business-government partnership’ — enforced at gunpoint.

  2. Dino Reno

    All we need now is a disruptive technology app like Uber handed out to every healthcare consumer to find medical care when required. Providers don’t need to be regulated our licensed, just willing to share the knowledge they have and whatever is in their medicine cabinet. Only in this way can we truly unleash the market forces that will drive down health care costs and provide creative entrepreneurs access to the largest segment of economy. More importantly, investment bankers could easily gin a trillion dollar market cap for any company tapping this market.
    In this sick society, today’s sarcasm is tomorrow’s reality.

  3. mellom

    Anybody wondering WHY we in the US ALWAYS are presented with such obscenely bad “choices” in anything health care related (and many other areas as well) by politicians would be well advised to look at US trade policy and the ever growing body of secretive “trade agreements” and (these are particularly illuminating) trade bargaining positions over the last few decades -the many bilateral and multilateral trade agreements.

    To put it bluntly, the US, no doubt because of the pharmaceutical industry and health insurance industries’, has made it a habit of writing clauses into trade agreements that ban both other countries and the US from having new or expanding existing public health care, which mandate the gradual incremental privatization of still-existing public programs, and that ban countries (including ourselves) from saving money on drugs using dozens of methods which are normal in say, European countries, etc. This trend is getting worse and the (leaked) policies that seem to be coming out of these negotiations seem to be getting worse very rapidly. A recent international arbitration case involving Slovakia shows the huge coat of these trade agreements to a country’s sovereignty to set their own health care policy.

    Here is a 2009 paper which describes a precarious situation with just one of the free trade agreements, the WTO services agreement, or “GATS”. Two potential mechanisms are at play, one is a standstill clauses which blocks all future “non conforming measures”, the other is the “investor-state” special corporate privileges. GATS was signed in the 1990s, so its not inaccurate to say that they have been lying to us for over 20 years, telling us that single payer might be possible, when in fact both parties have been supporting these trade agreements – for their big corporate donors, which unknowingly to the nation, block it.

    This situation needs to be made known and the incredible lack of foresight it represents, needs to be openly debated.

    This situation is so profoundly out of whack with what the politicians say and imply that it’s a huge scandal waiting to happen.

    1. Kmurp

      If the US is banned from expanding existing public healthcare as you claim, how is it that the US is expanding Medicaid??

  4. grayslady

    Formularies are standard for drugs now, its seems, even for Medicare. At least with Medicare, the insurance companies must send you the formulary in writing; but, yes, even under Medicare the most expensive drugs are always Tier 4 or Tier 5–meaning you pay substantially more out of pocket for those drugs.

    Also, Medicare, too, has its “gotcha” quirks. For example, a colonoscopy is considered a preventative service and, therefore, has no deductible. However, during the colonoscopy, if the doctor finds polyps and removes them, the procedure is no longer considered preventative and the patient will end up having to pay 20% of the cost of the surgeon, the hospital rental rate and the anesthesiologist. For those who don’t have secondary insurance, this can be a major expense. An alternate approach is to have an FIT test performed–which is also fully covered by Medicare–and if there is any evidence of polyps, at least the patient know that he or she will have to come up with the 20% cost of surgery and can price shop (if possible) for the most reasonable rates, as well as planning a savings program to pay for the procedure. Nowhere is this mentioned by Medicare in any literature, and most doctors are also unaware that a non-routine colonoscopy will cost the patient money.

  5. mellon

    A recent arbitration dispute before a European trade panel between Slovakia and Achmea, a Dutch company offering health insurance in the Slovakian market, over a 2006 law that limited Achmea’s profits and put Slovakia, or so they thought, on the path to a single payer healthcare system, illustrates the real reason “ObamaCare”, US healthcare policy over the last 20 years, and drug prices are so bad, a serious problem politicians are NOT being at all truthful with America about!

  6. impermanence

    “Where’s the justice in a citizen who lives on one side of the county line paying more for health insurance — and making life, or even life and death, decisions based on how much they have to pay — and a citizen on the other side paying less?”

    Lambert, because it costs more to deliver care in Manhattan, New York, than it does in Podunk, Mississippi. But this is just a distraction. Medicare reimbursements have always been dissimilar depending on the cost of doing business in various regions.

    The injustice you speak of is in putting forth the idea that people can act in self-destructive ways and have somebody else bail them out with heroic measures designed to enrich the few and bankrupt the rest. This is collective insanity.

    Only when people are willing to take responsibility for their own health will they begin to see that stealing from others [what all the wealth-accumulating/transferring activities essentially are] is the short road to Hell.

    1. scraping_by

      One part of commercial medicine justifying another part of commercial medicine is not a surprise. Especially when they’re mutually dependent. Especially when there’s a third party, the public, the citizens, who they can both feed off of. When the cost of delivering care is exaggerated, it’s no surprise the stories can grow bigger down the line. It’s just a question of what people will believe.

      While the wellness regime is useful, it has real and unavoidable limitations. People like to be told they have more control than they really do, but reworking that to a personal responsibility is adding a moral dimension it just doesn’t have. Creating the category of the undeserving sick has got the same motive and often the same agenda as the category of the undeserving poor.

      Jogging and wheat germ aren’t a viable substitute for arranging medical expertise in an efficient, effective system.

    2. roadrider

      Only when people are willing to take responsibility for their own health will they begin to see that stealing from others [what all the wealth-accumulating/transferring activities essentially are] is the short road to Hell.

      What a truly ignorant, insensitive, moronic pile of liberturdian bullshit.
      Many serious health problems are not the result of people failing to “take responsibility” for their own health. I have one – prostate cancer. Why? I lost some kind of genetic lottery. Should I have to pay my own way for treatment of this illness because you and others of your rancid ideological cult regard health insurance (public or private) as “stealing from others”. I guess neither you nor no one in your family ever suffered from an illness or had an accident. Can you guarantee that this will be the case for the remainder of your life and theirs?

      My other medical issues are common maladies associated with aging. Nothing I could have done to prevent them. I guess libertudians don’t get old either. I’m sure you’ll excuse me for “stealing from others” to avoid bankrupting myself to pay for the necessary medications and doctor visits.


      1. hunkerdown

        You know, we don’t actually have to listen to their whining and puling and indignant caterwauling about their beliefs in personal property. As a society, we can just ignore them and the principle in its entirety.

        That we have chosen not to says a lot about the value of one-way mass communications.

  7. scraping_by

    The ACA enrollment period often reminded me of a treasure hunt. The multi-million dollar PR machine kept tantalizing the public with tales of great deals while everyone else seemed to be slogging through the a swamp of corporate rules and bad offers.

    Interesting to learn if people think that getting the gotcha plan instead of the working plan is just bad luck, or they’ll figure out none of it makes sense if the point is arranging for health care. The Serious People are no help, so it will have to be in ordinary conversation.

  8. mellon

    Lambert, what they are saying is true. Americans don’t understand insurance. Insurers aren’t welfare agencies. Insurers have to make a profit. Insurance is a game, based on game theory, and bluntly, decent insurance enough for poor people costs a family $23,000 a year.

    Thats why we NEED single payer. there is no solution possible under the for profit system. Fake multipayer (i.e. “public option”) WONT SAVE ANY MONEY AT ALL. Obamacare, can’t possibly work. Why did they even do this, waste six years of our time. Because its a cover up. They had to – or be exposed as crooks going back 25 years, both parties.

    The government set these FTAs up and has been pushing them all around the world to stop the people from having democratic change when they needed it, which is now, when the 20th century style jobs start vanishing for good.

    They set the FTAs up – the elites of the oligarchical governments of the world, led by the US, to take these matters out of their own, (the governments’) hands, permanently, and make them a matter of international private law by giving entitlements to markets to corporations – arguably a modern form of serfdom.

    Stop trying to make sense of the ACA folks statements! The entire ACA is a trap for the unwary. A diversion.

    They were lying from the beginning in 2008, because they CAN’T deliver something which would work, not just because its been unaffordable for decades. They did it because, especially, over the last 25 years, they set up free trade agreements to block themselves from being able to change that, intentionally.

    The sooner the country sheds our naivete (“trust”, “hope” etc) the sooner we can get to the difficult work of straightening this mess out. Both parties have been lying like crazy to the American people. The sooner we face that, and demand REAL change (starting with honest government) the better.

    1. Propertius

      Obamacare is working perfectly at accomplishing its real goal: to so discredit government involvement in health care that we won’t see single-payer for at least a generation.

      Mission accomplished!

  9. mellon

    Note everybody, the phrase “average patient” or “average family” MUST be understood as meaning a family with NO sick members and NO need to see doctors. So, Obama’s average family paying $2300 less increase over ten years” is basically meaningless because insurance is for when people get sick. The cost to the sick – anybody with any kind of illness is basically 100% of their out of network/balance billed costs, plus their artificially low premium, plus the OOP Max. Each year. Many people will have to pay that OOP Max early in the year. (currently its around $12500 for most families, but in some cases- people who have two plan managers, it can be as high as $24000 this year!) So people should put money away to cover that OOP stuff, to avoid getting dumped when they get sick because they cant pay the huge, sudden extra bills. And of course, they also must pay the tiny premiums, which are in many cases subsidized.

  10. mellon


    As long as sick people immediately pay every penny that is demanded of them in a timely manner, they ARE covered.

    >I seem to recall that one of the big selling points for ObamaCare was that people with pre-existing conditions would be covered.

    Covered as long as they pay, yes. If they miss a payment, no. That’s the way the US for profit system works.

    >But here we see how the insurance companies are gaming formularies to prevent that.

    Isn’t that what they are supposed to do to maximize profits? If they can collect free money for twenty years and then somebody fails to make a payment when they get sick, and gets dumped, they have provided the service they are expected to provide. People don’t get any credit for that twenty years of paying on time.

    The US is the global poster child of medical injustice.

    >(As with doctors, it’s not clear how data would even be gathered to find out how widespread the problem is; but perhaps patient advocacy groups can help.

    The information is impossible to gather because the insurance companies change it all the time. Since they are for profit entities, they can and do claim everything is a trade secret or proprietary,

    and because of ERISA Section 514, they are basically protected and unaccountable from lawsuits.

    To be fair, they’re only doing that to AIDs patients

    The health insurance companies are in the business to make money so of course they are setting up the Obamacare plans to indeminfy them against losses. Somebody used a phrase “zero actuarial value plan” recently. Basically, the ACA plans are set up to be sort of pay as you go, if you get sick, with any serious illness, you’ll end up paying a lot.

    the alternatives would be either

    1.) going to single payer and everybody getting good healthcare, but the government would have to be responsible, unlike today. ALSO, WE WOULD HAVE TO DUMP THE FREE TRADE AGREEMENTS AND THEIR STANDSTILL CLAUSES AND INVESTOR STATE ENTITLEMENTS.

    2.), having everybody have to buy adequate private insurance (minimum price, $23-30,000 a year for a small youngish family, much more for many others such as older people or city dwellers) which would cover them adequately with acceptable levels of risk. Yes, it does cost as much as many people make. But thats what it costs – because the system we have now wastes a LOT. So, people would have to either make a lot more or spend much much less on everything else, give up their cars, move in with parents, work multiple jobs. Many businesses would collapse because people would stop buying. Nobody would be able to educate their children. We would rapidly lose our middle class.

    or 3.) The government would very encourage people to commit suicide if they got sick.

    >and people with MS, bipolar disorder, or dancer. So there’s that. If only there were a way to keep pharmaceutical costs low by giving the pharmaceutical buyer some leverage!

    They beat us to the draw on that one and for >25 years they have been in hundreds of little and BIG ways, anticipating the things which Americans and others would need to do to escape this trap, and with politicians cooperation, blocking them in trade agreements.

    Also, it seems clear that there has been an intentional media quarantine on news about the FTAs – just as there has been on single payer, so Americans don’t know any of this. At all, in fact, they are disbelieving when they are told. Its a sorry situation that is preventing anything from being done to fix the problem.

  11. Lune

    A lot of times even doctors get screwed thinking they’re in-network for a patient until a payment gets denied. If you’ve ever seen an “authorization” letter for services, you can see the fine print that says, literally “this letter is not a guarantee of payment”. IOW, even after an insurance company has “authorized” a service, they can still turn around and decide not to pay you after you go ahead and take care of the patient.

    Obama could have solved at least the narrow problem of figuring out who’s in network / in-formulary by simply making a centralized eligibility check. Insurance companies would be required to enter in their in-network provider lists and formularies into a standardized database, and providers / pharmacies could check the same database and get a reliable answer (as could patients at home before they even buy an insurance policy). The minimal cost to the government of running a server (this wouldn’t even have HIPAA privacy concerns: in-network lists are ostensibly public information) would have been far outweighed by the decrease in costs to providers using a multitude of private systems today, and would be hugely outweighed by the benefit of patients not getting thousand dollar “surprises” every time they wish to access care.

    Heck, even forcing insurance companies to provide standardized, public access to their *own* internal database of such information rather than merely marketing materials on a website, would have sufficed. Instead, both providers and patients get screwed because any sort of government service is labelled socialism.

  12. oliverks

    At the end of last year (2013) Anthem Blue Cross terminated our old plan, and placed us into a new plan costing 125% more because the old plan was no longer valid under ObamaCare. When we needed to find a doctor recently, we found the new plan has no providers within 50 miles of where we lived, where as the old plan had lots of good providers in our area.

    Now the truth is Anthem was probably super anxious to cancel our old plan because it was good and cheap. As with all insurance tales this is a long one, so please excuse this long post. We signed up for Blue Cross into what I will call plan A about 15 years ago, when we lived up in the bay area. I needed to get insurance as I dropped out of the work force and became an entrepreneur and later a consultant. Plan A became worse and worse.

    By the end of our time in plan A nothing even counted towards the deductible. That is no mater what the expense, it did even start the clock ticking against the annual deductible, let alone having the plan pay anything. Obviously we tried to switch, but by then we had moved to an area with less providers. Due to consolidation in the insurance industry, Anthem had become the main provider of insurance in our area. They would not allow us to switch plans, unless we went back through the same broker we had bought the original policy through.

    However the original broker was not allowed to sell us a new plan, because we had moved outside of their geographical area. Because they were making extremely good money out of us every year on plan A (I am assuming they might get 10-20% given the plan didn’t have any expenses) they weren’t prepared to release us and allows us to sign up for a new plan.

    Eventually a lawsuit filed by a lawyer who was stuck in the same crappy plan A as us (he wasn’t allowed to switch for similar reasons). It went to trial. The judge concluded that the plan A would never cover any health related expenses due to the restrictions in the plan. In essence, the plan by then had wording that allowed Anthem to never payout anything. As a punishment to Anthem he required Anthem to allow anyone on plan A to enter any plan they had at the lowest cost they charge any of their customers for that plan. This was a godsend. We signed up for plan B which was excellent and only a little bit more than what we had been paying on plan A.

    Well with ObamaCare they canceled our plan B as “it was not compatible” and placed us into plan C (how convenient is that). Now plan C was not as good as plan B and it cost us 125% more than plan B. Naively, we seem to get ourselves shafted again. We were told plan C was a PPO. As PPOs were required to cover certain expenses under ObamaCare how bad could it be, even if we had to go outside of the network.

    Early this year, we needed to find a doctor for my wife. Turns out, plan C had no providers in our area. So we checked to see what our costs would be going out of network. Amazingly plan C covers nothing again. How can than be if it is a PPO. Anthem then informs us, it’s technically not a PPO (even though it was sold that way), it’s an EPO. What’s an EPO you ask? I am still not sure, but it appears to be a merger where you take the worst aspects of an HMO and merge it with the worst aspects of a PPO, and then ensure their are no providers within 100 miles of any customers.

    The only silver lining here, is that there is a new provider in our area now (HealthNet) so we could switch to them. We are now on plan D, which costs what plan C does, but has worse benefits on paper. The good news is plan D at least has some decent providers in our area. As my wife has a per-existing condition, we are also fortunate that HealthNet had to accept us under ObamaCare, otherwise we would be really screwed.

    I can vouch for the narrowing of providers. We certainly experienced than on plan C.

  13. Joe Firestone (LetsGetitDone)

    I’ve never understood why Americans tolerate an insurance system that exposes them to such financial and health risks. Expanded Medicare for All is a no-brainer. Everyone should be in the streets demanding it. Ilog ago decided that the proper treatment for the insurance companies is to put them out of business.

  14. Brenda B Bottoms

    We have a situation with my 96 year old Mother. Our internist (that we have used for years) and his partners have sold their practice to another medical network. My Mother, who has a PPO with a network that was accepted by the practice, is now out-of-network. My choices are: Find a new internist (Lots of luck with a 96 year old) or pay triple co-pay for a visit to the Doctor. Also, all tests, procedures, etc are out-of-network. I’m not sure if prescriptions from the old internist are considered out-of-network, or if that means anything. Of course, this has happened in the middle of the year, out of selection period, so she is stuck until the next selection period this fall.

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