The Pitfalls of Healthcare

If you claim to like the Affordable Care Act also known as Obamacare then it really has not affected you directly. You either have employer provided health insurance, are so rich you can pay out of pocket for health services, you are on your parent’s plan, or you are on Medicare or Medicaid and do not directly pay your premiums. Otherwise you are young, healthy, or do not need medical care outside of annual checkups or preventative screenings all of which are covered under most insurance plans by law. I would guess that a majority of people fall into one, or more, of these categories. Don’t get me wrong, this is not a political post but rather the story of my experience with health insurance purchased through the website. It does not matter if you are left or right, liberal or conservative, or anything in between this is a direct insight into the consequences the law has had on me. When the law was being proposed I said that it was the wrong direction to take with healthcare. I stated that giving the federal government so much control over healthcare would be disastrous for a lot of people, especially those between 35 and 65 and in the middle class. I knew by how it was discussed on both sides that it would not work as intended, so fast forward a few years.

Shortly after the law was passed, I switched jobs. At my former job I did have insurance but I was working 72 miles from home and spending a lot of money on gas, not to mention an hour and half drive one way. I was offered a better paying job close to home (14 miles) through a temp to hire arrangement with an IT company based in Chicago. While that company did offer insurance, it was rather expensive and was limited outside Illinois so I opted to wait to get insurance until I was offered a full-time position with the company with which I was contracted. It was going to be 6 months to a year which was the average for temp to hire. Six months passed then a year and before long I was looking at two years in a temp to hire basis. The IT company did give me a raise and the contract company assured me that when they were able, they would hire me but at the time it was tough financially for them. In December 2016 I decided we needed to get some insurance before the new year and the fines would go into affect. We first tried to buy directly from Blue Cross Blue Shield but found the lowest plan we could get would cost more than $600 a month. We then checked Medishare, a Christian based medical sharing plan. But because I still smoked, we could not go that route. We finally visited the healthcare marketplace. This is where I first got a taste of what the Affordable Care Act had become and just how bad it had gotten.

In2010 we had private insurance (not through my employer) through Blue Cross Blue Shield for $313 a month which was cheaper than that offered by my employer. The insurance had a $5,000 deductible but covered office visits with $20 co-pays and $50 co-pays for outpatient services. The deductible did not come into effect until you were admitted to the hospital. For that time, this was great coverage. I had a hernia repaired and it cost me all of $50, including an overnight stay in the hospital. At the time I was an over-the-road truck driver and decided to become a local driver which paid less so I had to drop the insurance. It wasn’t until 2012 when I took a job with the state that I had insurance again. This insurance was just as good as the private insurance I had before. I was there until 2014 when I was offered the job I currently have. Because of the expense of the insurance and the fact it was limited, I decided not to get insurance due to the fact that the fines would not go into affect for at least two years. At that time, there were two providers on the marketplace, Blue Cross Blue Shield and United Healthcare.

When I had not been hired full-time with the company I was contracted for work and the fines would be implemented in 2017, I decided to take another look at the marketplace to see if there were any plans that would fit my needs. When I checked it out there was only one provider, Blue Cross Blue Shield, United Healthcare was no longer available. I also noticed that the plans had increased in price with the lowest price going from $54 to $131 a month. So I looked over the plans offered and what I found was disturbing to say the least. First, the lowest plan was $131 a month and it would cover all “preventative visits and screenings” but all diagnostic procedures are not covered until the deductibles were met. This plan had an over $10,000 deductible. The next plan was $350 a month and had a $7,200 deductible. As with the cheaper plan, it to did not cover diagnostic procedures until the deductible was met. The last plan offered was a whopping $700 a month but did have co-pays for office visits and some outpatient procedures. The deductible was still $7,200 but would only be applicable in hospital admissions. I felt we were in good health so we chose the one we could afford which was the $131 a month plan. It would have been $600 without the subsidy.

I purchased the plan in January but it did not go into affect until March. I decided since I had coverage for an annual exam that I would go to my doctor. He did the exam and blood tests and I thought all was fine until I got a call from his office. He informed me that I was iron deficient and we needed to find out why. I knew I had rectal bleeding from hemorrhoids but did not think they were the cause. My doctor sent me first to have that checked and it was found they were not bad enough to need surgery. That is when they sent me to a Gastroenterology doctor that ordered a colonoscopy and EGD. I was scheduled and ready for the procedure when the surgical facility called and told me that I would need to have $875 for the procedure. When I consulted my insurance provider they informed me that because I am not yet 50 that the colonoscopy was considered a diagnostic test it would only be covered after my deductible was met. At the time, I only had $215 paid toward my deductible. I did not have the $875 so I had to cancel the procedure until I could save up the money which, on my own, would take months. I wondered why it was set up this way that is when I found out what the law really did.

The Affordable Care Act, Obamacare, or the healthcare law as people have called it did two things that caused this dilemma. First it mandated that everyone must have insurance coverage which caused the rates to increase due to the inclusion of preexisting conditions and high risk patients into the marketplace. Second, it divided the services into two categories, diagnostic and preventative, while allowing very high deductibles on lower rate plans. This was to entice young, healthy people to get the lower rate insurance because they would only need preventative coverage. This is when I found out the difference between diagnostic and preventative services.

Preventative services are any tests or screenings used primarily to check the overall health of a person. These can include blood tests, urine tests, and X-rays for most all insured people. Some have age limitations such as the colonoscopy and mammograms. In my case it was the colonoscopy. I am 44 and the law states that you must be 50 or older for the colonoscopy to be considered preventative. This is due to the recommendation of the healthcare community that has set the prime age for screening at 50. The problem is that the law does not take into account the caveat that was also put forth that those with a family history of colon cancer or have high risk factors should be screened earlier. This means that a 30 year old person with a family history and/ or risk factors would still not be covered for the screening due to their age. My problem was that the colonoscopy order by the doctor was considered diagnostic in nature.

Diagnostic services are also tests and screenings of the same nature as preventative services but performed because there is a known issue for this reason the test is considered diagnostic. For instance, if a 50 year old man has a colonoscopy ordered without symptoms or indications of illness, the test is preventative. But if the same man has an order for the same procedure because of symptoms or abnormal blood test it becomes diagnostic and therefore falls into the area of covered after deductible. It is the same procedure for the same man, the only thing that has changed are the circumstances for the procedure. This is how it was explained to me by my insurance provider. This is a direct result of the healthcare law.

You might ask why I did not buy the top plan in the marketplace or at least the middle plan. It all boils down to finances. When I had the insurance in 2010 I had fewer bills than I do now. My wife was the caregiver for her mother who could no longer drive so my wife was the one to take her to doctor’s appointments and dialysis three times a week. Her parents in turn would help with gas and other things so we had more disposable income available to us. Since that time, her parents have passed away and we are buying a home and we are helping her son and soon to be daughter-in-law by maintaining the car insurance and cellphone (which was a plan her dad was able to get and we can’t get a better deal) for the family. So when it came to picking a plan, we were limited on what we could spend. The $700 plan was out because it was way too expensive, our mortgage is less than $600. The $350 plan may have been manageable but would have left no room for savings or added expenses. We settled on the $131 plan thinking we would only use it for annual checkups and any savings we would get on prescriptions. That is when we were hit with the unexpected.

Due to the way the coverage is, I need to raise $875 or more to cover the cost of the tests I need. I can save the money up on my own but it will take a while during which time my condition, whatever it is, may go from treatable to not treatable and that is the concern I have. To help in this endeavor, I have started a Go Fund Me page and have already reached the halfway point. So anyone who is reading this and wants to help you can donate here . Thank you for reading.


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