The NJ Obamacare exchange plans; why don’t any of these seem like a good deal?

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The NJ Obamacare exchange plans; why don’t any of these seem like a good deal?

An investigative report by William D. Charschan DC,CCSP

If you are buying a plan under the NJ exchange (providing you have actually been able to get past the processing part) , you may notice that there are a limited number of insurance carriers participating in the exchange at this time. You may also notice the list price for plans that cover a low percentage of the office visit, with a high yearly deductible is high, and healthcare republic, a plan designed just for the exchange seems like a good deal until you realize that there is no out of state coverage which begs the question; what happens if you get ill out of state?

On Bill Maher’s program, Anthony Wiener (yes, that Anthony Wiener) who blew up his city mayoral campaign showed he is actually a brilliant politician when he stated that Medicare for all would likely take over since Obamacare actually forces us to use plans that have a built in overhead of 20-25%, vs. Medicare’s 3% administrative costs. As I have mentioned in a previous post, I had stated that I predict that in five years, we as a country go to single payer. Apparently, there are others in the government who predict this will be the future reality.

While the news media is all over those losing their coverage (usually for vastly inferior plans that are not at all comprehensive), or experiencing huge increases in their premiums when a plan that is more comprehensive replaces it, the problem is the overall cost in this country, something Obamacare does not fully address. Most people are unaware that the average in network doctor is making much less now than they did per visit in 2000, courtesy of the insurance carriers, yet, as doctors spent less time, and ordered more tests, the cost of care exploded. $950 for an MRI, $4000 for a sleep study and more, yet, the lack of time primary doctors now spend is a huge part of the over testing problem, especially since the doctor can no longer afford to spend the time necessary to troubleshoot your problem.

Those of you who visit our office may notice we do make the time, however, we have been able to streamline operations to a more significant extent than most primary doctors can, so we are less harmed if we spend the time, yet the time spent often is curative. 40 years ago, most primary doctors would spend the time, however, you paid your doctor for his time, and practice was less complicated than it is today with many third party insurers, their requirements, their games, their claim and care denials, etc.

Our course, to understand where much of the money goes and went, check out Stephen Brills article on healthcare costs located here. Since this article is really about Obamacare and the value of the new NJ plans, here is what was found on the exchange on 11-12-13

sample plans

While upon first glance, this may be a bit confusing; simply, if you live in a high cost of living state like NJ you are quite unlikely to be helped by the government when you buy a plan. If you want to check it out for yourself, Kaiser has this healthcare subsidy calculator

Plans are listed from catastrophic through platinum, the most comprehensive. In NJ, there are three plans that are included in the marketplace including Amerihealth, Horizon and Health Republic (administered by Qualcare, NJ based PPO).

You must be careful because even though some plans seem cheaper, the devil is in the details. An example is that under Health Republic, you can get their Core Gold plan for your entire family for $1267.64, what seems like a bargain when compared to what I am currently paying Oxford which costs us over $1700 per month in their EPO plan, a plan with no out of network benefits. See it for yourself here. Since there is no out of network coverage, if you have a problem and are out of the state, they include emergency care only (which is undefined). If you see someone out of the network, you are on your own so this can be a good deal if you never leave NJ and like their selection of doctors. Personally, the thought of saving almost $500 per month is great until you also realize that if someone is hospitalized, or has a test, you are hit with a $2000 deductible, or $4000 per family.

The Amerihealth National access Gold plan is closer to what I have currently, with better coverage for tests such as an MRI and a lower deductible for a lower cost than what we have now, while including a national network. Without looking further into this, this plan at $1476 seems like a better deal, and apparently uses their new EPO network, but allows visits to all providers without referral, however, according to their website, this network has no out of network benefits. That is where the similarity ends with my current plan. To take this, and save about $300 monthly, if you decide to visit an out of network doctor, you are without any coverage whatsoever. This makes this not such a good deal if you believe you need to go beyond the network to help yourself. This can be a problem with certain specialties such as neurosurgery.

Blue Cross does not even list a similar plan, and to confuse the public, they introduced new plans under the advance and advantage names. It is my understanding that neither of these has any out of network benefits (although, I would expect that since Blue Cross Blue Shield is national, there is national access) and their advance is a more budget minded network with fewer healthcare providers and for some reason, only 5% of the chiropractors were placed in this network, while all the physical therapists were allowed. This was a discriminative move in my opinion, especially, since some of the best and most cost effective providers I know were not allowed in, and neither were we.

What have your learned from this sample

1. The web site is useless.

2. If you live in a high cost state like NJ where you need to make more to live here, you will not qualify for any subsidies.

3. This is just from the individual side of the exchange. If you own your business and are buying coverage for the business and its employees, you will have more plans to choose from and other options.

4. All these EPO plans force you to give up the right to go out of network, yet forgo coverage. This is a great deal for the insurer since they tell you up front that if you go out of network, they have no responsibility.

5. More comprehensive plans will cost more, yet, do we get more for our money? From what I have seen, no.

6. Medicare for all would be a much better deal offering;

a. A wider assortment of doctors in all states, just in case you like to relocate to a warmer state during the winter.

b. Out of network benefits.

c. Better negotiated rates since they are negotiated nationally with more clout (see Stephen Brills article mentioned at the beginning of this article)

d. Healthier hospitals (eliminating Medicaid is better for a hospitals economic health).

e. A simpler and more effective healthcare system that is less costly to operate in.

f. rates that would likely be 25-30% lower right now than those in the exchanges.

Of course, this is just the tip of the iceberg, we need to turn the healthcare system upside down and rethink our disease care model, the time doctors are allowed to spend and how they get paid if they do and the rewards for quality (something yet to be defined) rather than how many tests one orders.

What do you think? As always, I value your opinions.