Insured, but Not Covered
WHEN Karen Pineman of Manhattan received notice that her longtime health insurance policy didn’t comply with the Affordable Care Act’s requirements, she gamely set about shopping for a new policy through the public marketplace. After all, she’d supported President Obama and the act as a matter of principle.
Ms. Pineman, who is self-employed, accepted that she’d have to pay higher premiums for a plan with a narrower provider network and no out-of-network coverage. She accepted that she’d have to pay out of pocket to see her primary care physician, who didn’t participate. She even accepted having co-pays of nearly $1,800 to have a cast put on her ankle in an emergency room after she broke it while playing tennis.
But her frustration bubbled over when she tried to arrange a follow-up visit with an orthopedist in her Empire Blue Cross/Blue Shield network: The nearest doctor available who treated ankle problems was in Stamford, Conn. When she called to protest, her insurer said that Stamford was 14 miles from her home and 15 was considered a reasonable travel distance. “It was ridiculous — didn’t they notice it was in another state?” said Ms. Pineman, 46, who was on crutches.
She instead paid $350 to see a nearby orthopedist and bought a boot on Amazon as he suggested. She has since forked over hundreds of dollars more for a physical therapist that insurance didn’t cover, even though that provider was in-network.
The Affordable Care Act has ushered in an era of complex new health insurance products featuring legions of out-of-pocket coinsurance fees, high deductibles and narrow provider networks. Though commercial insurers had already begun to shift toward such policies, the health care law gave them added legitimacy and has vastly accelerated the trend, experts say.
The theory behind the policies is that patients should bear more financial risk so they will be more conscious and cautious about health care spending. But some experts say the new policies have also left many Americans scrambling to track expenses from a multitude of sources — such as separate deductibles for network and non-network care, or payments for drugs on an insurer’s ever-changing list of drugs that require high co-pays or are not covered at all.
WHEN Karen Pineman of Manhattan received notice that her longtime health insurance policy didn’t comply with the Affordable Care Act’s requirements, she gamely set about shopping for a new policy through the public marketplace. After all, she’d supported President Obama and the act as a matter of principle.
Ms. Pineman, who is self-employed, accepted that she’d have to pay higher premiums for a plan with a narrower provider network and no out-of-network coverage. She accepted that she’d have to pay out of pocket to see her primary care physician, who didn’t participate. She even accepted having co-pays of nearly $1,800 to have a cast put on her ankle in an emergency room after she broke it while playing tennis.
But her frustration bubbled over when she tried to arrange a follow-up visit with an orthopedist in her Empire Blue Cross/Blue Shield network: The nearest doctor available who treated ankle problems was in Stamford, Conn. When she called to protest, her insurer said that Stamford was 14 miles from her home and 15 was considered a reasonable travel distance. “It was ridiculous — didn’t they notice it was in another state?” said Ms. Pineman, 46, who was on crutches.
She instead paid $350 to see a nearby orthopedist and bought a boot on Amazon as he suggested. She has since forked over hundreds of dollars more for a physical therapist that insurance didn’t cover, even though that provider was in-network.
The Affordable Care Act has ushered in an era of complex new health insurance products featuring legions of out-of-pocket coinsurance fees, high deductibles and narrow provider networks. Though commercial insurers had already begun to shift toward such policies, the health care law gave them added legitimacy and has vastly accelerated the trend, experts say.
The theory behind the policies is that patients should bear more financial risk so they will be more conscious and cautious about health care spending. But some experts say the new policies have also left many Americans scrambling to track expenses from a multitude of sources — such as separate deductibles for network and non-network care, or payments for drugs on an insurer’s ever-changing list of drugs that require high co-pays or are not covered at all.
Medicine Just for You
President Obama’s new budget contains a farsighted proposal that could ultimately transform the practice of American medicine. The proposal seeks to design treatments for the individual, which are sometimes called “personalized medicine” or “precision medicine” to distinguish them from the one-size-tries-to-fit-all approach.
Despite the potential of the program, the president’s enthusiasm may have overtaken the science at times. He promised in his State of the Union address that the initiative would “bring us closer to curing diseases like cancer and diabetes.” We’ve heard that “cancer cure” talk for decades, yet the delivery date is still far off.
The fiscal 2016 budget would make an appropriately modest start. It gives the initiative $215 million the first year, with $130 million going to the National Institutes of Health to develop a research cohort of a million or more volunteers willing to share their data; $70 million to the National Cancer Institute to scale up efforts to identify the genomic drivers of cancer; $10 million to the Food and Drug Administration to hire experts, regulate diagnostic tests and develop databases; and $5 million to an office that works on standards for health information technology to protect the privacy of data. Certainly this is one area of the $4 trillion budget where both parties in Congress should be able to put aside their partisan bickering.
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