I'm not sure it is or will work that way, in practice - the more preventative care, less emergency room part, anyway.
The total cost of my health insurance premiums is about 20k/year; some of this is subsidized by my employer. I have a $4500 deductible. The insurance does not pay for anything, outside of preventative care, until I've paid $4500. After that, they contribute 80% up to some number, $7500 I think, and then they contribute 100% until the end of the calendar year.
Because I have such a high deductible, and due to the opacity of medical billing, I am not going to the doctor unless I'm pretty sure that not going to the doctor means I'm going to be put out of work or going to die. "Preventative" care is defined very strictly: you get a physical. For example, "preventing" the development of pneumonia by treating your respiratory illness early does not count as preventative care.
The best I can do is squirrel away what I can in my HSA...but that's one health catastrophe from being blown away. God forbid I come down with any kind of chronic illness that lasts longer than the calendar year.
That said, for the poor population, this is definitely true - Medicaid is a dream compared to private insurance. At least in my state, if you're on Medicaid, you don't even see medical bills. It's really lamentable the states were allowed to turn down the Medicaid expansion - the expansion of public health insurance was the best part of the ACA, in my opinion, and the most regrettable part of the bill is that the public option is not available to everyone.
About $7500. I would be surprised if your costs are radically different - be sure to account for any employer or government subsidy for health insurance premiums.
Also, those numbers include only in-network providers. If I am given out-of-network care - which isn't always under my control - then I could potentially be on the hook for tens of thousands more dollars.
But the concept of in-network and out-of-network coverage isn't a new to the ACA, or that different. There are plans with national network coverages - so why are you going out of network?
I wouldn't deliberately, but there are plenty of situations where someone might inadvertently be given out-of-network care.
- An out-of-network providers gives you medical attention at an in-provider facility - maybe your ER doctor, surprise, is not in-network, even though the hospital is in-network. [1] [2] [3]
- Maybe you have a medical emergency and the closest facility at the time is out-of-network. (In some states and with some insurers under some circumstances, you can get them to pay the difference for emergency out-of-network care.)
The biggest risk factor is the "normal" <= $7500 medical bill from an in-network provider, but inadvertent out-of-network care is still something you have to be concerned about.
Also, I'm not sure if I'm reading you right, but "in-network" does not necessarily have anything to do with geography - sure, there exist in-network providers for my insurance throughout the country, but the second-closest hospital to me is still out-of-network.
EDIT: The HN backoff must be crazy high - 40 minutes later, and I still can't post, and I'll be offline the rest of the day.
Because the ACA didn't fix it. From my perspective, it was largely a giveaway to private insurance companies with some fortunate side effects.
The total cost for my health insurance premiums are 20k a year.
My in-network deductible is $4500.
My in-network out of pocket is $7500.
My out-of-network out of pocket is $20k.
Those are not hypotheticals, and because of those costs, I avoid medical care unless it is absolutely necessary. I'm afraid we're getting into the weeds - my main point is that the ACA's preventative care provisions are really quite weak and don't mean what we might think they'd mean; the preponderance of high deductibles and out-of-pocket maximums mean that people will continue to avoid getting prompt medical care until their condition becomes serious. The preventative benefit, mainly, is that everyone gets a yearly physical and a few other narrow types of preventative care.
The total cost of my health insurance premiums is about 20k/year; some of this is subsidized by my employer. I have a $4500 deductible. The insurance does not pay for anything, outside of preventative care, until I've paid $4500. After that, they contribute 80% up to some number, $7500 I think, and then they contribute 100% until the end of the calendar year.
Because I have such a high deductible, and due to the opacity of medical billing, I am not going to the doctor unless I'm pretty sure that not going to the doctor means I'm going to be put out of work or going to die. "Preventative" care is defined very strictly: you get a physical. For example, "preventing" the development of pneumonia by treating your respiratory illness early does not count as preventative care.
The best I can do is squirrel away what I can in my HSA...but that's one health catastrophe from being blown away. God forbid I come down with any kind of chronic illness that lasts longer than the calendar year.
That said, for the poor population, this is definitely true - Medicaid is a dream compared to private insurance. At least in my state, if you're on Medicaid, you don't even see medical bills. It's really lamentable the states were allowed to turn down the Medicaid expansion - the expansion of public health insurance was the best part of the ACA, in my opinion, and the most regrettable part of the bill is that the public option is not available to everyone.