You would find yourself with new Medicaid coverage when you were previously self-pay, with very little in the way of patient responsibility. Then we’ve got the health insurance exchange products, where the subsidies run for individuals with adjusted gross income between 138 percent and 400 percent of the federal poverty limit, and that’s the process that we’ve been discussing now. I just wanted to make that distinction.
Explore This IssueACEP Now: Vol 33 – No 01 – January 2014
“The offer of health insurance ‘coverage’ is essentially false advertising. What really matters is what the out-of-pocket maximum is under the plan and how much ‘real money’ individuals and families are going to have to come up with.”
—L. Anthony Cirillo, MD, FACEP
Dr. Klauer: Tony, what are your feelings about whether this is just the illusion of health-care coverage? If people really are not going to want to pay this out-of-pocket expense anyway, they’re going to be in the same situation they’re in now. What do you think?
Dr. Cirillo: Let me give you a real-world example because I’m actually on the Connecticut exchange website right now. If you have a family of four in Connecticut, and I did two adults and two teenage children with an annual income of $60,000—that’s gross income—there are four silver plans that are available through the Connecticut marketplace, the cheapest of which, after a $520 tax credit, is $405 a month.
So that’s the premium. The max out-of-pocket for the year is $12,700, and it comes with a $6,000 deductible. So I would pose to the group: if you’re a family of four making $60,000 a year and you have to shell out $5,000 a year in premiums and you’re on the hook for $6,000 to start with, are you really going to be able to afford that coverage?
Dr. Klauer: So when it comes down to it, this is a shell game. You’re still paying $11,000 before anybody pays one penny of coverage for your family.
Dr. Cirillo: That’s correct. And your primary-care visits have a $30 co-pay. As Mike pointed out, there are three concepts that people need to consider when they’re looking at this—really four. OK, I’ll give you five: What’s the premium? What’s my deductible? What are my co-pays? My coinsurances? And then, what’s the maximum that I’m on the hook for when I get my card?
Dr. Klauer: Is there any carve-out in any one of these plans that you’re aware of that says, but if this is an emergency, we cover more of this or you don’t have to meet the deductible?