Mama's Got a Plan:

Maternity Care, Health Insurance, and Reproductive Justice

Time served

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Governments manage to build roads, regulate air quality, invade countries – however imperfectly and occasionally inappropriately. So I am moderately hopeful that my new health insurance plan, purchased through the marketplace set up by the Affordable Care Act, will be an improvement, even if only because of the generous tax credit that subsidizes my premiums.

That said, if time spent could be parlayed into dollars, I might be able to forgo the tax credit. Although my search for insurance for the adults in our family was neither quick nor easy, I can’t blame the ACA or even healthcare.gov. Much of the complexity was the result of my family’s economic circumstances and the structure of private health insurance.

Essential tool: crystal ball

I was surprised when healthcare.gov asked me for proof of income for 2014 – frankly, I would like proof of income for 2014 too. Neither healthcare.gov, the federal exchange, nor a local navigator were able to tell me what documentation I could reasonably provide for income not yet earned – or even conceptualized! [Time spent on phone calls and internet chats: approximately 2 hours.]

Out of necessity, I invented a solution: I will submit my final pay stub from this year, even though it is not a reflection of my income for next year, as evidenced by the fact that I will also submit a letter from my employer confirming that I am no longer receiving paychecks. My husband will submit a “self-employed ledger”; because no one is able to tell us exactly what that means, we will concoct a spreadsheet of business income and expenditures and hope that it suffices. I give healthcare.gov credit for not requiring that documentation be uploaded before selecting a plan. [Time spent gathering documentation so far: 1 hour.]

What’s my point? The ostensible purpose of the ACA is to provide affordable care by means of health insurance to people who would otherwise lack access. It’s not a long shot to say that a large number of people in this situation are those whose employment is sporadic, variably paid, or simply unpredictable. Demanding proof of future income defeats the purpose of providing easier access to care for this population.

Dental …

Our family is blessed with relatively good health, with the notable exception of My Teeth. Thanks to genetics and my tendency to send stress directly to my jaw – and believe me, I’m grateful it doesn’t go to some other body parts – I am very familiar with dental care. Health insurance, on the other hand, has always considered dental care to be a separate, alien entity. When I searched for plans within my price range that also included dental care, I found one, for which our out-of-pocket cost for the premium would be higher than we’re currently paying, even taking the tax credit into account. Naturally, I wanted to be sure this costly plan was worth it, so I carefully examined the dental benefits. While I was on hold with the insurer, I also hopefully text-chatted with healthcare.gov, to no avail. The insurer was finally able to clarify several of the “Benefit Explanations” regarding frequency of coverage of fillings. For anyone who’s wondering: “1x per 48 months for permanent teeth” means as many teeth as need to be filled in 48 months  (subject to plan maximums, of course), just not more than once in any given tooth during that time. Perhaps I was overly suspicious of that language; however, I have forked over plenty as a result of past misunderstandings of policy language. [Time spent on hold: 1 hour.]

After looking at the numbers again, I decided to investigate dental riders available directly through the insurer. I reasoned that if such a rider cost only about $50 a month, as it did in our pre-ACA individual plan, we could easily buy one of the more cost-effective health care plan without dental benefits. I had questions regarding:

  1. My dentist’s participation in a provider network, the meaning of which was far from clear on the insurer’s website;
  2. Whether as a result of my dentist’s possible participation, I would or would not be charged for the difference between the insurer’s approved amount and my dentist’s charges;
  3. Whether the deductible on the dental rider worked as a group or individual deductible.

 

After another long wait, I was connected with a customer service representative who was apparently puzzled by my questions. His answers included the word “probably” and once directly contradicted a benefits summary document, which itself was careful to state that it was not a contract – the legal equivalent of crossing your fingers behind your back. I was far from reassured. [Time spent on hold: 1 hour.]

However, I was gratified to discover that I could purchase the dental rider through healthcare.gov. I am almost certainly overestimating the scope of government oversight on private plans, but I felt that going through the exchange would provide me a layer of protection against the excesses or obfuscations of the insurer. We’ll see how that plays out when I deal with my first claim.

What’s my point? I am thrilled that it is possible to purchase a separate dental care rider through the exchange, but knowing that from the start would have saved me a number of steps. Better-informed customer service representatives staffing insurer phone lines would also be helpful, but I am under no illusion that this falls under government dominion.

… and mental

Mental health care has traditionally been as alien to the average insurance plan as dental care. The Mental Health Parity Act of 1996 sought to address this problem, but in the end did little to require plans to offer routine mental health care.

My hope was that our new health care plan would pay the mental health care professional seen regularly by our family. I found, however, that our provider was out of network for all of the plans available to us. In order to receive any coverage at all for her services, we needed to buy a plan with premiums more expensive than our recently expired plan. When I did the math, the best of those plans would cost us $200 more a month than the less expensive plan we were considering, and due to deductibles, coinsurance, co-pays, and a maximum 50% reimbursement, would save us at most $400 a year. This was the final impetus for us to discard that plan. [Time spent examining provider networks and crunching numbers: 40 minutes.]

What’s my point? Plans continue to prioritize coverage for inpatient mental care over outpatient care, and reimburse providers accordingly, thus providing less incentive for providers to participate. While inpatient care is more expensive and thus especially deserving of coverage, it is a mistake to neglect coverage for outpatient care, for the simple reason that regular outpatient care can significantly reduce the possibility of needing inpatient care. When outpatient coverage requires substantial out-of-pocket expenditure, patients are less likely to continue that care.

Just the facts – but where are they?

I haven’t described the process of sorting through possible plans, seeing whether our providers participated in those plans, constructing a spreadsheet to compare the plans, running through various health care needs scenarios to test the numbers, or any of the other tasks required to make a decision of this importance.  [Time spent: 6 hours.]

What’s my point? I am struck again and again by how unlike other purchases it is to buy health insurance. Consumers must predict what they will need to spend, in a market where costs are for the most part indiscernible. Customers must predict what they can afford to spend. Customers must decide whose services they will need should some of their scenarios come to pass.

Time and again

I’m grateful for the ACA and the chance to buy health insurance that actually allows us to receive medical care. Under our old plan, the deductible was so high that it was hardly even worth getting an annual physical: had an exam unearthed issues that needed further study or treatment, it would have been too expensive to follow up. The only answer would have been to buy a lower deductible plan – one that charged unaffordable premiums. The ACA cut through that problem to some degree by aligning income eligibility with insurance costs through the tax credit.

But the problem it didn’t solve was the vast amount of time needed to organize insurance. I’m an educated, privileged person with a computer, a fast network, and enough free time to make endless phone calls and sift through the benefits – or lack thereof – of various plans. Even so, getting coverage has taken weeks and is not yet completely resolved.

What’s my point? If I were an economist assessing citizens’ productive labor capacity, it would concern me that so many of us are must use our time to get something that other developed nations take for granted: access to affordable health care. After watching several British TV medical dramas, I reported to my family that I couldn’t get over how every patient expected care – and got it! I hope the ACA will make a dent in our nation’s problems that are responsible for this sort of amazed perception on my part, for the obvious public health reason that populations are healthier when they can access quality health care. However, setting aside health outcomes, I can’t help imagining the things I might have accomplished in the time I spent identifying and purchasing a workable health insurance plan. Multiply that by everyone buying plans on the exchange, and we potentially have the 21st century equivalent of Sputnik – some giant leap we might have made as a nation, but didn’t.

Furthermore, I am under no illusion that my work is done; past experience tells me that each time I have contact with the health care system, six months of phone calls and paperwork with my insurer ensue. It is in the financial interest of insurers to avoid reimbursing care and they count on the inability of most of their customers to take the time to vigorously pursue claims. I do not relish the prospect of disproving their expectations, but I cannot afford not to. When I had employer-based health care, I could count on my H.R. department to wage some of these battles for me. Now it’s just me against the insurer.

All this time! In which, perhaps, I could have written another article, looked for a new doctor for my children (due to their change of health plan – more about that in another post), lobbied legislators, done more laundry – you name it. Let’s hope it will have been worth it.

With luck, my next post will mark the beginning of my new health insurance plan.

 

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