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Viewpoint: Helplessness, despair, and terror - the Affordable Care Act and MNsure

By Pete Sorensen

Red Wing

Helplessness is a terrible feeling. Thousands locally and millions of people across the nation are now experiencing this feeling. They are truly unable to afford coverage for health care. What feeling is worse than this? Possibly the feeling of despair many will experience once they get hurt or sick and then deal with potentially losing everything they worked to accumulate over their working lives.

The Josephsons and Johnsens are fictional, but their circumstances are entirely accurate.

The Josephsons are 63 years old, earn about $65,000 per year and live near Miesville. They just learned their premium for health care coverage is $20,000 next year and they would need to pay $13,000 out of their pocket before any benefits would be paid from the insurance carrier. If either of them were sick or hurt, $33,000 or over half their income would go to pay for health care.

They were very upset but did not feel quite as bad for themselves when they learned their good friends and neighbors, the Johnsens' new premiums alone are $33,000 for the same type of plan. This potentially could cost them $46,000 for health care or over 70 percent of their $65,000 annual income.

The Josephsons and the Johnsens are both couples and are the same age, but the Josephsons live in Dakota County and the Johnsens in Goodhue County. The price for the Josephsons' coverage is certainly unaffordable by anyone's measure and is ridiculous. However, the price for the Johnsens' coverage is 65 percent higher and is plainly outrageous.

Some may wonder why the families cannot rely on the Obamacare "tax credit subsidy." Neither couple qualifies since they earn too much money. Many of those with incomes qualifying for the premium tax credit subsidies believe they cannot afford to pay the deductible if they get sick. In turn, they are refusing to sign up, preferring to go without coverage and pay the penalty tax.

Please note the following actual event: Even when you believe you have so called "affordable" coverage as Mr. Dennis, an assistant vice president for a bank in Virginia, learned, there is no guarantee you truly have affordable coverage.

Terror arguably may be a more dreaded feeling than helplessness or despair. Terror is exactly what Dennis experienced when he thought he was dying in May 2014. He was forced to sign a "consent for services and financial responsibility form" in order to be treated at the hospital he was in when he thought he was having a heart attack. He had insurance coverage and his carrier paid over $27,000 for the tests during his two day hospital stay.

However, since Dennis' insurance carrier did not have a "network agreement" with the hospital, the hospital demanded over $111,000 for services and sued Dennis for the balance of $84,000.

After a trial, the judge ruled that Dennis owed another $500 since $27,500 is what the 75 percent discount would be had he negotiated prior to services, as if he was uninsured. An approved network provider would have only paid $24,000 and Medicare $20,000.

Dennis' experience with balance billing is one that many patients are now dealing with right here in our community from our health care provider. A number of states have prohibited "balance billing" when "reasonable payment for services" has been made by the patient or their insurance carrier.

The cost of care problems associated with the health care industry and the ACA are many and complicated, but just dumping the increasing insurance premiums to the taxpayer is not reducing costs and the price of coverage. Obviously, government has to step in, but in a different way. The health care industry dominated by big insurance, big medical, big pharma, and big government has failed us. Health care starts with the personal relationship between provider and patient.

Employers sponsoring medical coverage must also be seen as a customer by the medical providers and be more actively involved in making sure their employees have good quality care at a fair price. A better approach is for community employers to spend more time shopping for health care than health insurance.

The National Association of Insurance Commissioners has developed a model act, in light of the narrowing of provider networks to deal with balance billing also referred to as "surprise bills." Many patients are receiving "out of network" charges even when receiving treatment at "in network" facilities.

Professor Timothy Jost representing the NAIC is critical of health care provider "charge masters." He explained, "Charge masters are notorious. They have nothing to do with cost, competitive prices, or what hospitals collect from anybody, but are just fantasies."

As pointed out, the pricing problems for medical coverage are many and complicated. Outlawing unfair, abusive provider billing schemes is a good place to start.