So one of the impacts of the way this has been structured is that it is forcing first-dollar coverage onto individuals and basically making them self-insure.
Explore This IssueACEP Now: Vol 33 – No 01 – January 2014
What’s funny about it is that when you take into account the individual cost from coinsurance and deductibles and then you add in the additional amount of premium you’re going to pay for a lower coinsurance or deductible, and you take pregnancy as an example, you just about pay the same amount out-of-pocket regardless of plan. And that amount out-of-pocket is almost the entire cost of the pregnancy.
“If the good news about the Affordable Care Act is that in half the states we can look forward to more Medicaid patients, then I think that fairly well summarizes what we can expect for emergency medicine in this initiative.”
—Todd Taylor, MD, FACEP
Dr. Granovsky: I’ll just add here, related to the out-of-pocket maximum. The out-of-pocket maximum seems like it will apply to co-pays and coinsurance. The patients’ premium costs, which are paying for the actual coverage, may in the end actually be layered on top of that. And depending on the way that the insurance product is set up that you purchase, you may be on the hook for prescription drug co-pays in addition to the $6,350 out-of-pocket maximum.
In fact, I’m in the process of shopping for my own family’s health insurance, and the prescription coverage is an area where there’s a lot of opportunity for the issuers, the insurance companies, to pass on costs. As an example, a typical plan that I looked at just yesterday was a $10 co-pay for a generic drug but 40 percent coinsurance for a non-generic drug. The math changes very quickly. That non-generic drug, which happened to be Protonix, was going to be $100 for a 60-day supply.
Pondering the Impact of Policy Cancellations
Dr. Klauer: Mike, what is your perspective on the surprise that initially 5 percent, or 15 million people, got their policies canceled? Was that a surprise? What’s the impact of that issue? Do you think the federal government knew but were just waiting to see how it played out?
Dr. Granovsky: It seems like it was a knowable fact ahead of time because the requirements to grandfather a plan were very, very well vetted. Then secondarily, the essential health benefits were very, very clearly defined. To the extent that an old plan did not have those benefits, it was clear that plan would be canceled.