Health insurance vs. access to healthcare

Guest CommentaryFebruary 25, 2014 

As many are finding out there is a huge difference between being insured and accessing medical providers. The Affordable Care Act (Obamacare) has mandated that all individuals purchase health coverage or be penalized for not doing so.

Many people have gone onto the California Exchange (Covered California) where subsidies are available for help with premiums for those who qualify. They have purchased coverage assuming they would be able to access providers but in many cases this is proving difficult.

The act required minimum benefits for all plans and the way in which claims ratios were calculated was reconfigured. This has resulted in carriers reducing compensation to providers and other partners (insurance brokers).

As a result a large percentage of providers have refused to become plan providers for many Preferred Provider Organization (PPO) plans. PPO plans in the past have generally provided larger networks and easier movement between primary care physicians and specialists. Providers have generally preferred PPO's to Health Maintenance Organization (HMO) in that they provide a fee for service compensation model. HMO's use a different compensation model and more hoops to jump through with referrals to specialists, approval of tests etc.

This is a generalization to be sure but fairly representative of the insurance market prior to Jan. 1, 2014. This is now going through a massive change. The fee for service compensation model is proving unattractive to many hospitals and providers who have refused to sign on with several carriers' PPO plans and are instead signing contracts only for the HMO plans that carriers are offering.

To compound the issue many carriers are showing on their provider directories online that specific providers are accepting plans when in reality the provider is not.

So consumers are signing up for plans where they think their provider is contracted, scheduling visits or procedures and finding out that although they are insured, the providers they wish to use are not in the network and are having to go find a provider who is, or look for another plan to purchase before March 31. There are at least four providers in Oakhurst who now are 'not' accepting PPO plans with carriers that they previously did prior to Jan. 1. However they were showing up on the insurance carriers website as contracted.

I have spoken with individuals representing a major Fresno hospital network and provider network who have indicated they will not be contracting their provider network into several carrier PPO networks, only the HMO. The economics do not work and they do not expect the carriers to offer any increases in the current compensation being offered for PPO plans. Carriers simply cannot offer more if premiums are to remain at, or anywhere near, their current levels.

So the goal of making insurance available to everyone has been achieved but it appears "access to health care" is diminished. With our urgent care center appearing on life support at best, both emergency care and routine care will be more difficult to obtain here in Eastern Madera County. To be fair there are providers here that are accepting PPO plans, just fewer then there were.

It is very possible that we will see a two tier system of medical care. Some providers will decide to sign contracts with all plans including Medi-Cal seeing many patients a day. Others will not accept these plans and will instead accept fewer plans, see fewer patients, while spending more time and charging more for their services in relation to the first class of care. This was beginning to happen prior to the implementation of the act and will likely accelerate.

This is not an indictment on insurance carriers, hospitals, providers or the Affordable Care Act. /15 of our economy has just been adjusted and actions have consequences. This is one. This is but a sketch of the issue boiled down for space accommodated to highlight the problem.

There are six weeks left in this first ever open enrollment period. When shopping for coverage we advise you call your providers to make sure what plans they are accepting so you can make informed choices in purchasing health insurance coverage that allows you "access to health care."

There is a difference between being insured and having "access to health care."

Doug Macaulay is co-owner of Macaulay Insurance Agency of Oakhurst, and has been a health insurance broker since 1983.

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