Pains and Gains: Marketplace insurance offerings vary on affordability (Part 2)

Larry Keller doesn’t mince words when it comes to how he feels about the country’s health law.

“A typical Cincinnati conservative would rather slit his wrists than consider a so-called Obamacare policy," Keller said. "But no exaggeration, I wouldn't be here if it weren't for the Healthcare.gov website.”

The West Chester Township resident was among nearly 29,000 Tri-State residents to buy a health insurance plan last year sold through the new online marketplaces ushered in by health reform.

While Keller credits the coverage for saving his life, putting the benefits to work came with big challenges and a hefty price tag: $676 a month to cover him and his teen son.

Keller’s experiences – good and bad – are shared by millions of consumers who, in the last year, tapped into newly offered insurance benefits.

For many, the new coverage has come with big monthly discounts, saving millions of families hundreds of dollars each month.

Some still worry, because of other high out-of-pocket costs, that they won’t be able to afford the care they need if they get sick.

Consumers like Keller were shocked to learn that the coverage they bought didn’t cover the doctors they wanted.

Still others complain: "Going to my doctor was cheaper for me when I didn’t have health insurance," said Cindy Bastin of East Price Hill.

Under health reform, most Americans must buy insurance or face steep financial penalties come tax time.

Those who aren’t insured this year face a penaltyof $325 per adult or 2 percent of the household income -- whichever is higher, when they file 2015 taxes.

In 2016, the penalty jumps to $695 per person, or 2.5 percent of a family’s income. For a family of four that’s uninsured, the minimum fine is about $1,000.

“They’re looking at losing an entire tax return – or more - and so many are saying they just can’t afford not to have insurance,” said Angela Robinson, an outreach and enrollment specials with the Cincinnati Health Department.

Can I afford this health insurance?

Cathy Barney's family budget has a little more wiggle room.

The Milford family of four is saving more than $500 a month on its health insurance plan thanks to tax credits offered through the new health insurance marketplace, Healthcare.gov.

“Finally, after all of these years of buying health insurance on our own, there is some relief,” said Barney, who in the past paid nearly $1,000 a month.

Nationally, 85 percent of Americans who bought a plan through marketplaces qualified for federal tax credits, saving them $264 a month on average.

Average savings across Ohio, Kentucky and Indiana ranged from $250 to $336 a month.

The web-based marketplaces, also called exchanges, are cornerstones of health reform and considered critical for consumers like the Barneys who are self-employed.

Still up for debate is just how affordable the insurance plans really are – even after tax credits are applied.

More than 80 percent of the plans sold through the marketplaces in 2014 had deductibles of $2,500 or higher, according to research from The Advisory Board.

“There is concern that these higher deductible plans will cause consumers to forgo or delay care because of the cost," said Reem Aly, director ofHealthcare Payment and Innovation Policy at the Health Policy Institute of Ohio.

For 57-year-old Cindy Bastin, that’s exactly the case.

“We just don’t go to the doctor unless we’re really, really sick,” said Bastin. She is paying about $500 a month for health insurance that covers she and her husband.

The couple’s deductible is $9,200, even after receiving a tax credit worth more than $430 a month.

That leaves them paying out of pocket for costly prescriptions that add up to more than $300 a month.

“Thank God we own our home and cars, otherwise we’d have to make the choice between paying for those or our health insurance,” says Bastin. “It just worked out better for us when we didn’t have to have health insurance.”

Advocates say more in-person help and education is needed as people shop and buy plans on the marketplace. The true cost of health coverage involves complicated calculations demanding an understanding of insurance lingo like deductible, in-network and out-of-pocket costs.

“This can be an overwhelming experience for folks,” said Trey Daly, Ohio director of Enroll America, a national nonprofit working to sign up the uninsured. “For many, this is their first experience shopping for health insurance. It’s an issue that is very personal, very intimate and very complicated. That’s why assistance is so critical.”

In spite of hurdles, coverage is worth it, he said.

Among the most fundamental changes brought on by health reform last year is the banning insurers from denying coverage to people with pre-existing conditions.

Armed with that knowledge, West Chester’s Keller went insurance shopping on Healthcare.gov in late 2013, eager to buy coverage that would help battle colon cancer that had spread to his liver.

It wasn't easy.

“The various policies that are offered have names like they are in code or something,” he said. “It's hard to tell exactly what you are buying and if you are comparing apples to apples as far as price is concerned. It can be very difficult to see if a particular doctor or hospital is in a company's network.”

Keller eventually chose a Humana Gold plan for he and his son. The plan saved him $200 a month over his previous policy. He made too much as a lawyer to qualify for a tax credit, he said.

His plan covered more than his earlier catastrophic-coverage plan, which didn't cover preventive care and also required him to spends thousands for his medical care.

But there was a catch: Keller’s surgical oncologist at University of Cincinnati's Barrett Cancer Center wasn’t an in-network provider.

Like millions of who bought a plan through the marketplace, Keller’s policy was with a health maintenance organization (HMO). Such plans limit consumer choices for providers as a way to cut costs and offer lower rates.

Just days before his scheduled surgery, Keller received notice from his insurer that the procedure was not covered because he chose an out-of-network provider.

After spending hours on the phone battling with his insurer, the surgery was approved – with his insurer striking a deal that would allow the surgery to be done at an in-network price.

A year later and cancer-free, Keller said he’s thankful for the coverage but thinks more can be done to help consumers understand what they’re buying.

“It would be great if you could just type in the name of the doctor or hospital, and then the website gives you a list of which insurance policies include that provider in their networks,” he said. “Going through the provider page for each policy can be tedious and frustrating."

Keller went shopping through the marketplace again this year – and he scheduled an appointment with a certified application counselor who helped him confirm his networks and costs.

“It's all kind of intimidating,” said Keller. “But in the end, it's worth it."

Photo Credit: Lisa Bernard-Kuhn / WCPO