Although the Affordable Care Act expands private health insurance to millions of Americans and provides financial assistance along the way, affordability of essential services remains a barrier to many, consumer advocacy group Families USA said in a report Thursday.
The organization pushed health insurers to offer more silver plans, the most popular exchange option, with lower out-of-pocket costs and affordable premiums. It also urged lawmakers to mandate insurers sell at least one silver plan with lower cost-sharing for common services such as doctor visits and prescription drugs.
“Gaining health coverage too often still leaves healthcare unaffordable due to high deductibles and other out-of-pocket costs,” Families USA Executive Director Ron Pollack said on a call with reporters. “This needs to be fixed.”
More than a quarter of adults who purchased individual health coverage on the ACA exchanges last year said they skipped medical procedures or did not buy drugs because they cost too much, the report said. High-deductible plans were cited as a primary culprit. Even people who make below 250% of the federal poverty level said high out-of-pocket costs weighed on their mind. People below that threshold qualify for cost-sharing subsidies that can be used for deductibles and copayments.
Using data from the Urban Institute, Families USA said about 43% of exchange members bought plans with deductibles of at least $1,500 per person annually. About 1 in 4 people had plans with annual deductibles of at least $3,000 or more per person.
Previous reporting has shown high deductibles dominated the ACA's open-enrollment period the first two years. High-deductible policies allow people to pay lower premiums, but policyholders are responsible for first-dollar coverage of healthcare services until the deductible is met. The plans are also becoming more widespread among employers.
The most recent open-enrollment period showed high-deductible plans represented upwards of 80% of exchange options in some regional markets. The average silver-plan deductible is about $2,900 for individuals and $6,000 for families, according to HealthPocket, a website that analyzes health insurance information.
Under the ACA, preventive services such as blood pressure screenings and flu vaccinations must be covered by health insurers at no cost. New data from the HHS released Thursday show 137 million people have private coverage of preventive care with no cost-sharing.
However, if those preventive services lead to other medical care, the costs of that care are generally applied to a person's deductible. “A more consumer-friendly benefit design would cover some services even before enrollees pay the full deductible,” Families USA said in its report. For instance, the group recommended more plans pay for outpatient services like blood work and diagnostic tests before the deductible is reached.
Insurance companies contend consumers can't have it all. If health plans have lower deductibles, then premiums must be higher to account for that choice and risk. And insurers argue employers and exchanges are giving people the freedom to choose what works best for them.
“There are high-deductible plans, but there are also low-deductible plans,” Humana CEO Bruce Broussard told Modern Healthcare in April. “The ability for an individual to choose what is most important to them as they consider their health status and their risk tolerance is a great opportunity.”
Lydia Mitts, a senior policy analyst at Families USA and one of the authors of the report, said there is “no evidence” that creating silver-level plans with low cost-sharing should lead to dramatically higher premiums.
The group also called on other state marketplaces to follow the lead of California, New York and others that have created standardized plans. These state-specific requirements often exempt routine care such as lab tests, generic drugs and urgent-care visits from the deductible.
