Some newly insured still struggle to pay for health care

CHICAGO – For Martha Gruberman, a 63-year-old resident of Steger, Ill., obtaining health insurance through the Affordable Care Act hasn't made it any easier to pay for routine medical care.

A plan she chose through the federal marketplace requires her to pay $5,000 toward medical costs before her insurer contributes anything. With an income of about $22,000, she doesn't expect to hit that mark.

"I'm never going to use it," she said. "I can't use it. I can't afford it."

Gruberman and others who picked plans with the lowest monthly costs have found that medical care is still out of reach because of the plans' high deductibles. As a result, many consumers with high-deductible plans are following old habits: delaying care or taking their needs to community health centers that have traditionally served the uninsured, local health administrators said.

"These people, even though they have access to some form of insurance, really do not have health care," said Suzanne Hoban, executive director of Family Health Partnership Clinic, a free and reduced-cost clinic in Crystal Lake.

Officials have cited the number of people who signed up for private insurance last year as a measure of the federal health law's success. About 217,000 Illinoisans signed up, exceeding federal expectations, and about 7.1 million Americans enrolled during the law's first open enrollment period. But about 63,000 Illinoisans enrolled in low-premium bronze plans, which last year had a median deductible of $5,600 in the state and for 2015 have a median deductible of $5,750. Plans in the other categories – silver, gold and platinum – cost more per month but have lower deductibles and better benefits.

Administrators at free and charitable health care clinics in the Chicago area say they are adapting to new challenges posed by those among the newly insured who need help paying for care. The challenges are expected to grow next year.

Premiums for the cheapest bronze plans in Illinois are increasing by an average of 11 percent in 2015, according to state data. In the Chicago area, that means a 40-year-old will choose among bronze plans that have an average premium of $243 and a median deductible of $5,000, lower than the state median.

Annette Kopczynski, 62, of Huntley, signed up last year for a $6,000-deductible bronze plan with Blue Cross Blue Shield of Illinois. After tax credits, her monthly premium is $38. She said she sees a nurse practitioner at a reduced cost at Family Health Partnership Clinic because she cannot afford care through her insurance. She and her husband, who is on disability, pay about $25 per month toward the costs that accrue, she said.

"I don't really go for tests or things that would cost, like physical therapy," she said. "I would never do that. I'm just lucky. I'm mostly healthy. I just try to stay away from the doctors."

Like other free and charitable clinics, Family Health Partnership traditionally served the uninsured. But this year the clinic changed its policy to accept people with insurance who can't afford care, said Hoban, the clinic's director.

"This is a paradigm shift for us," she said.

CommunityHealth, a Chicago-based free clinic that serves 11,000 patients, is considering making a similar change next year, said Judith Haasis, CommunityHealth's executive director.

"We're going to consider serving individuals who are doing everything right, but when they look at the options won't be able to access routine or medical care because the cost of accessing that care is going to be too great," Haasis said.

Free and charitable clinics serve many of the people who qualify for federal tax credits. The credits help offset premiums for those who make up to 400 percent of the federal poverty level, or about $46,680 for an individual and $95,400 for a family of four in 2015.

Serving the low-income population puts the clinics in a position to observe the health law's impact on a key group it was meant to help.

"We were excited and we still think it was a very positive move forward, but there are definitely some things that need to be tweaked in there," Hoban said.

The newly insured are also turning up in greater numbers at NorthShore Community HealthSystem hospitals, said Cindy Geaslin, NorthShore's director of patient registration.

NorthShore offers financial assistance for people who need it. With more high-deductible plans, the hospital is seeing more patients who have insurance but request help, she said. The system also has stepped up education efforts to help people understand the complexities of premiums, deductibles and co-pays.

"We've been doing this since before Obamacare, but I can tell you that the increase in questions and the increase in patient education has really spiked," she said.

Deductibles were rising before the health law passed, as employers sought to keep premiums low for workers, said Ceci Connolly, managing director of PwC Health Research Institute.

"This is across the board one of the most popular strategies for trying to contain health care spending," Connolly said.

The average deductible for an individual in the employer insurance market was $584 in 2006, according to the Kaiser Family Foundation. In 2014 it was $1,217, according to the Foundation.

The Commonwealth Fund, a national health research foundation, recently surveyed 19- to 64-year-olds who had insurance through employers and the federal marketplace in the past year. Among those with low incomes, 3 in 5 said their deductibles are difficult to afford. Two in 5 who had high deductibles relative to their income said they had delayed needed care because of the deductible.

While high-deductible plans sometimes contribute to poor health care decisions, they also force people to think more carefully about medical spending – a shift that could help contain medical costs and slow premium growth, another goal of the federal law, experts said.

"I can't say it's a direct cause and effect with high-deductible plans, but it does suggest to us that everyone in the system is doing a better job of managing care and managing the cost," Connolly said.

All plans come with a set of free preventive services including cancer screening, immunizations and diet counseling. Since the health law passed, use of those services has increased, and young people are seeing primary care doctors more often and hospital admissions are starting to level off, Connolly said.

As consumers confront the nuances of health care, some patient advocates are looking for ways to simplify the way it is sold. Insurance companies have traditionally sold plans to businesses who offered their employees a few options, said Katherine Hempstead, who directs the Robert Wood Johnson Foundation's work on health insurance coverage.

"This is a product that wasn't designed to be sold to consumers, but now it's being sold to consumers, and the design hasn't changed that much," Hempstead said.

The foundation is sponsoring competitions for developers to create tools that will help consumers select from the array of plans on the federal marketplace – there are 288 non-employer-based plans offered in Illinois this year. The tools would likely create algorithms that would narrow plans based on the medications people take, specialists they see and other personal health information.

"There are so many plan design features that people need to look at," Hempstead said. "It's not just the premium. It's not just the deductible – it's what is covered with this deductible."

Kopczynski said she picked the cheapest plan she could find last year. This year she plans to look more carefully at the options, including whether a new hospital being built nearby will be in her network.

Gruberman, of Steger, said tax credits made it possible for her not to pay premiums in 2014. She has been receiving help paying her medical bills from Access To Care, an organization that coordinates reduced-cost medical care throughout Cook County. Her premiums are going up to $67 per month for 2015, she said. She plans to try to find a cheaper plan.

"I will have less coverage, probably a higher deductible than I have now. But I can't afford to pay anything out. I don't make that kind of money," she said.

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(Chicago Tribune reporter Alex Richards contributed to this report. This story was produced in partnership with Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.)

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