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For Some, Affordable Care Act Costs Still Out of Reach


When Joan Fiander of Annandale, Virginia, checked what might be available for a close relative making $9.50 an hour and working full-time, for instance, she was gratified to discover the family member would qualify for subsidies that would keep her monthly insurance cost below $50 a month.

“She was very excited, very excited,” Fiander said. “This is the first time in a long time that she’s gotten a break.”

The law also provides lower-income consumers reduced payments for deductibles and copayments for doctor visits or hospital care. But that help ends after household income hits 250 percent of the poverty level. 

After that level, the law caps out-of-pocket payments to a maximum of $6,350 annually for an individual, or $12,700 for a family.

Insurers must provide certain preventive care services for free, such as cancer screenings and some vaccines. And some plans may also offer doctor visits or other services for a small payment without triggering the deductible. But visits to specialists, buying prescription drugs and hospital stays are among the medical services likely to cost more in the form of copayments and deductibles.

Experts Recommend Coverage

For La Voie, who makes less than 200 percent of the federal poverty level, the law caps out-of-pocket costs at $2,250 for individuals. (Her children are covered by a public plan so she would be looking at an individual policy.) Additionally, New York caps people in her income range to a $200 annual deductible and $2,000 in out-of-pocket costs. 

Policy experts say that she’s better off buying a plan even if it’s a struggle because she would be covered for a broad range of benefits. They point out the costs would be far less than if she landed in the hospital as a result of a serious illness or accident and was uninsured.

“People without insurance now are either foregoing health care they would otherwise want or need, or are getting health care but racking up debt,” said Sarah Lueck, senior policy analyst with the Center on Budget and Policy Priorities. 

La Voie fits the bill. She has put off treatment for an episodically painful gall bladder problem which she worries could put her in a hospital emergency room. If that happened, she “would have no choice” but to work out a payment plan to cover the treatment.

Nevertheless, she plans to take that chance because paying the fine for not having coverage is more affordable.

“For now, I’m going with the penalty,” she said. “I would love to have insurance but I also want to [be able to] pay for rent and groceries.”

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communications organization not affiliated with Kaiser Permanente.

Tue, Sep 24 2013

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