Dr. Matt Prosser’s dental practice is small, and he likes it that way.
“I take care of one patient at a time,” he said. “I guess I’m old fashioned in that way; I like to give my patients my full attention and the time they deserve.”
But his small practice has come with some big headaches in recent years. Because he has only three employees - all of whom have health insurance through their husbands - Dr. Prosser has had to purchase his own family’s health insurance through Healthcare.gov, the Affordable Care Act exchange.
What he’s learned - and what many Texans are now finding out - is that every insurance company but Blue Cross Blue Shield has pulled out of the exchange in much of Texas, and the only policy Blue Cross will sell for 2017 in East Texas is a health maintenance organization (HMO) plan, at a far higher cost than last year. Prosser said he doesn’t know what he’ll do, with the open enrollment period starting in just a few days, on Nov. 1.
“We’re looking at options, but there aren’t any good ones,” he said. “We could consider maybe doing a small group (employer) plan here at the office, but my staff doesn’t need it and it would be more expensive. But we would really like to not have to go with the HMO that Blue Cross is offering - the doctors don’t like it any more than the patients do. So like I said, we’re looking at options.”
What’s the difference between an HMO and the preferred provider organization (PPO)? Under an HMO, policyholders must choose between a very narrow range of physicians and services; typically, any services beyond office visits require a referral from the primary care physician. Under a PPO, the range of providers and benefits is wider, and in-network services usually don’t require a referral.
“When you look at the ACA (compliant) plans, you see them broken down into bronze, silver and gold levels,” Prosser explained. “We were used to having a $2,500 deductible. But to get the same level of coverage in an HMO, we’re looking at a $10,000 deductible. Who has that kind of money?”
Even with the higher deductible and less coverage, the Blue Cross plans being offered for 2017 will cost much, much more in monthly premiums.
Take the Silver Plan, the most popular option offered by Blue Cross. Under the $3,000-copay version of the plan in 2016, a 50-year-old East Texan is currently paying a monthly premium of $459.44. In 2017, that monthly premium will be $752.92 - an increase of 58 percent.
With the higher deductible of $3,500, the monthly premium in 2016 is $406.57. In 2017, the monthly premium will be $642.38 - also a 58 percent hike.
Blue Cross Blue Shield of Texas posted a statement last week regarding its participation in the health insurance marketplace in 2017.
“For 80 years, Blue Cross Blue Shield of Texas has been committed to providing access to quality, cost-effective coverage to as many people as possible through employer group plans, government programs and individual policies,” the statement reads. “We will continue to work with state and federal regulators and legislators to ensure a stable and sustainable insurance marketplace and to improve the quality and cost of care for all of our members.”
Dr. Prosser has relied on Linda Sellers, of Sellers-Patterson Insurance, for decades. They’re old friends, but she said she had no good news for him.
“I don’t think the general public has any idea what’s coming,” Sellers said. “A lot of people have gotten letters from Blue Cross, telling them about the changes. They’re not happy.”
The problem in Texas was entirely foreseeable, she explained.
“In the state of Texas, we had a high risk (insurance) pool,” Ms. Sellers said. “That pool took all of the very sick people, and it was running very well. It was adequately funded. But then along came the Affordable Care Act, and it was done away with - and all of those very sick people were added to the regular insurance market.”
In 2013, the Texas Health Insurance Pool, which served about 23,000 Texans, was shut down in accordance with the Affordable Care Act.
As the Texas Tribune reported at the time, “The state has deemed the high-risk pool obsolete, as the Affordable Care Act prohibits insurance companies participating in the federal marketplace from denying coverage to Texans with pre-existing conditions.”
Ms. Sellers said she watched the insurance companies hike their rates and eventually pull out of the marketplace.
“The math doesn’t work,” she said. “We’ve added so many people to the health care system, making it implode under its own weight. I’ve told my clients lucky enough to have grandfathered policies to do what they can to keep them.”
LAWS OF ECONOMICS
Dr. Deane Waldman, director of the Center for Health Care Policy at the Texas Public Policy Foundation, said what’s at work here are some simple laws of economics.
“What Washington did with Obamacare has created a monopoly position for Blue Cross in Texas, for Anthem in parts of California, for various other insurance carriers elsewhere, as long as they were willing to put up with the massive increase in costs,” Waldman said. “And, of course, they pass those costs on to the public. Meanwhile, other companies can’t afford it - United Healthcare, Aetna, Humana. These are companies who have done their math and are pulling out. Anyone left is in a monopoly position, and we are at their mercy.”
United Healthcare has confirmed it will leave Texas’ ACA exchange in 2017.
“United Healthcare will not be participating in the individual exchange in Texas in 2017,” spokeswoman Maria Gordon Shydlo said in an email last week. “While individuals will continue to have access to their health benefits through the end of 2016, if they are current with their plan premiums and continue to meet eligibility requirements, they will need to choose new plans during the upcoming enrollment period to ensure they have health care coverage in 2017.”
We’re a long way from “if you like your doctor, you can keep your doctor” and “a family of four will save $2,500 every year on their premiums,” said Dr. Prosser.
“I’m not politically active, but I’m watching what’s going on here,” he said. “The ACA has been a disaster. I had one of those grandfathered plans, and I’ve seen my premiums go up 20, 30, 40 percent every year. Back before the Affordable Care Act, all of the hospitals took Blue Cross, and all of the doctors were in network. It was a very good plan and I was happy with it, never had any problems with it. Until this Affordable Care stuff.”
RESPONDING TO CRISIS
Even President Obama acknowledges the ACA is in trouble. He’s now appealing to Republicans in Congress, who were shut out of the design of the ACA, to help him fix it.
“No president can do it alone,” Obama said Thursday at an event celebrating the ACA. “We will need Republicans in Congress and in state governments to act responsibility and put politics aside.”
At the event, Obama pointed out that the ACA has resulted in many more Americans obtaining insurance. That’s true, but nearly all of that increase comes from the expansion of Medicaid - something Texas and several other states declined to do.
Professionals in the medical community aren’t any happier about the situation than consumers are.
For example, in 2017, the Blue Cross plan available through Healthcare.gov will only be affiliated with East Texas Medical Center Hospital and the University of Texas Health Center at Tyler.
That leaves out the region’s other large health care system, Christus Trinity Mother Frances Health System. So Christus has announced its own plan, available through the Healthcare.gov site, which will be ACA compliant. There are few details yet about premiums and deductibles, but a Christus spokesman said the plan is an effort to address the gap in coverage left by the withdrawal of the big insurance companies.
“Last year was difficult for our community, there were so many families affected by the changes to the in-network providers in the health insurance marketplace. These patients were left with no options to continue their care at Christus Trinity Mother Frances Health System,” said Christus vice president John Webb. “We are excited about the launch of Christus Health Plan, because patients will once again have the choice to seek their health care from Christus Trinity Mother Frances Health System through the health insurance marketplace.”
In Washington, U.S. Sen. John Cornyn has gone to the Senate floor to criticize the ACA, which he said has “been a disaster for Texas.”
“The fact is, consumers will have less choice and their health coverage will come at a higher price,” Cornyn said in September. “According to one estimate, 60 counties out of our 254 counties in Texas will have just one health care option in 2017.”
FINDING A FIX
Congressman Louie Gohmert, R-Tyler, said he expects the ACA ultimately will fail, and Congress must be ready to design a replacement.
“I believe (President) Barack Obama wanted single-payer health care all along,” Gohmert said. “But he knew we’d never get there in one step. So the first step was to propose an unworkable system, in which insurance companies would find it hard to stay in business.”
The ACA has failed to live up to its promises, he said.
“And the truth is we can’t just repeal Obamacare and return to the health care system we had before,” Gohmert said. “That system was sick, too.”
But the sicknesses had the same root cause, Gohmert contends - excessive government regulation and involvement.
“If we want to get health care back on a healthy track, we’ve got to leave the decision to the doctors and the patients,” he said. “What I find in East Texas is that people are learning when government is paying their doctor, they’re not getting the care they need. And the Affordable Care Act has become the disaster that we knew it would be.”
The Texas Public Policy Foundation’s Dr. Waldman agreed.
“Root cause of the problem, in essence, is the federal bureaucracy,” he contended. “It’s the combination of overregulation and diversion of dollars from health care to health care bureaucracy. Over $1 trillion in health care spending doesn’t produce $1 in health care service. It’s overhead, IT, communications, administration, regulators and inspectors. We have to reduce that bureaucracy and that complexity.”
For now, though, East Texans will have to continue to work through Healthcare.gov and with limited choices.
For Tyler’s Dr. Prosser - who has spent his career as a dentist dealing with insurance companies - it’s discouraging.
“My health is good and my wife’s health is good, knock on wood,” he said. “We’ve had a couple of trips to the ER for unexpected things, but nothing big. But still we’ve gone from a $500 deductible to a $2,500 deductible and who knows where it will go after that.”
Still, other families have it harder, he said.
“Look at my son,” he said. “He’s in IT in Houston. He’s on an ACA plan from the exchange. They just had a baby, who needed some emergency surgery at about three months. But the deductible was just so high. They’re having to finance a $6,000 deductible with the hospital. That’s quite a hit for a young couple.”
Open enrollment in the ACA exchange starts Nov. 1 and runs through Jan. 31.