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Shots - Health News
Wed December 25, 2013
A Texas Social Worker Weighs Her Insurance Options
Originally published on Wed December 25, 2013 5:23 pm
Texas has the highest rate of uninsured people in the country, with almost 1 in 4 people going without coverage.
One of them is Tammy Boudreaux.
Boudreaux, 43, lives just outside of Houston and works as a freelance psychiatric social worker, with no benefits.
She has been skipping mammograms and other checkups for years. "It's worrisome," she says. "It's like gambling. Gambling with my health, and it is very frustrating."
The federal government has already extended the deadline for enrolling in health plans under the Affordable Care Act. But even with HealthCare.gov working better lately than it did in October and November, it's still unclear how many consumers will want the plans.
The government and insurers need uninsured people, especially those who are healthy, to sign up, but many may decide it's better for them to pay a penalty.
Boudreaux has logged on, looked at the plans and remains largely unimpressed.
She figures she spent about $1,500 on medical care this year, including a trip to the ER for a cut finger. She also takes a few prescription drugs and occasionally sees a psychiatrist and a nutritionist.
She can't get insurance through her partner, Laura Perez, because her employer doesn't offer benefits to same-sex couples.
Boudreaux was hoping to find a better deal on HealthCare.gov. She likes the monthly premiums that she sees but has balked at the high annual deductibles.
"Let's say if I paid the $178 a month, my deductible would be $5,000," she says. "I would have to pay up to $5,000 before I received any kind of payment from my insurance company."
Boudreaux could get a lower deductible if she paid a higher premium, but about $200 a month is what she feels she can afford. She doesn't qualify for subsidies to help pay for a policy.
"I don't smoke. I'm relatively healthy. So I was pretty insulted when I saw this," she says. "I was extremely angry actually. I felt hoodwinked by the insurance companies: 'Oh, here's this wonderful insurance plan but by the way you need to come up with $6,000 out-of-pocket first before we pay for anything.' "
That reaction is typical, says Caroline Pearson, an analyst focused on the new health insurance marketplaces for the consulting firm Avalere Health. "A lot of people aren't ever going to get out of that deductible," says Pearson. "Only if you have a catastrophic health event or you're really chronically ill will you ever hit your out-of-pocket cap. People are left, I think, feeling like, 'I spent a lot of money this year on the premium, and I didn't get any meaningful coverage from my insurance.' "
But Pearson says people forget two things if they just focus on the high deductible. One is that the new plans must offer some free preventive services, such as mammograms and yearly physicals. The other is that having a plan protects you from medical bankruptcy if you are in an accident or face something like a cancer diagnosis.
That's because the Affordable Care Act requires that health plans have a yearly limit on out-of-pocket expenses. If something serious did happen to Boudreaux, she wouldn't pay more than $6,350 in the year.
It's a dilemma for Boudreaux who says she has considered the possibility that something catastrophic can happen. "That is a huge fear — what if," she says.
But if nothing happens, she thinks she'd pay less just continuing to go along on her own. And she could put the $200 that would go to the monthly premium into a savings account.
In any case, Boudreaux doesn't feel any urgency to sign up right away. She's been uninsured for a few years, so what's a month or two more?
And with the holidays coming up, this is one difficult and confusing decision she'd rather just avoid for now.
"Whoa, shut the computer," she says. "Find something else to do. There's something much better I could be doing with my time than trying to figure out this rigmarole of insurance policies and deductibles and what's covered and what's preventative and what's included and blah blah blah. It's not very well explained."
If Boudreaux doesn't enroll in a plan by the end of March, her tax penalty would probably be a few hundred dollars — for the first year. The penalty starts out at $95 or 1 percent of income in 2014 and rises in later years.
This story is part of a partnership among NPR, KUHF and Kaiser Health News.