Having health insurance and physical access to health care providers, hospitals and pharmacies won't help you and your family if it's unaffordable. The Affordable Care Act (ACA) defines affordability of employer-provided health insurance as premiums that are less than 9.69% of a household's income.
However, the premiums used to determine "affordability" are those for the individual only, not for her entire family. Little wonder, then, that family health insurance premiums can cost considerably more than 9.69% of a family's household income. This complication is called the ACA's "family glitch" and is a policy problem that can prevent families from buying lower cost health insurance through ACA marketplaces.
Indeed, as with all ongoing debate regarding the ACA, the "family glitch" is an issue HealthyWomen will continue to monitor it as part of our overall work on Affordability and Access to Care.
Aside from monthly premium costs, affordability can also be an issue for women and families in the form of deductibles or cost-sharing, including flat-dollar co-payments and co-insurance, which involves charging a patient a percentage of a service's or product's total cost.
When examining the affordability of health insurance, it is important to remember that it should not be looked at as "pre-payment" for what health care services and products you and your family might expect to use in the coming year (although that should certainly be part of your evaluation of potential insurance plans). Rather, insurance should be considered a fundamental protection against unexpected health issues that can lead to very high costs.
It is important to remember, too, that while monthly premiums can be high and some health insurance plans can have deductibles of several thousand dollars, most non-Medicare health insurance plans set limits on what people have to pay after their premiums. For 2018, the maximum annual "out-of-pocket" limits for ACA insurance are $7,350 for individuals and $14,500 for family coverage.
Traditional Medicare does not have a limit on annual out-of-pocket costs, while Medicare Advantage plans do have annual limits on out-of-pocket costs. However, Medicare Advantage plans usually feature closed networks of clinicians or charge higher costs for out-of-network clinicians or providers. (Learn more about concerns about Medicare Advantage plans here.) Women buying health insurance for themselves and/or their families may have several options. While insurance available through the Affordable Care Act (ACA) marketplace exchanges (healthcare.gov), must meet all the requirements of the ACA, (including not excluding people or charging higher premiums because of pre-existing conditions, coverage for preventive services without cost, and coverage of maternity care and prescription drugs), other insurance options may be available with lower premiums. However, those lower-priced options may not meet the ACA requirements and may not include coverage for certain services — in particular, maternity care or prescriptions — and may have very high deductibles, and annual or lifetime caps on benefits.
HealthyWomen opposed proposals to expand dramatically those types of health insurance plans, including Association Health Plans and Short-Term/Limited-Duration health plans because they will be able to discriminate against women based on their gender, age, or pre-existing conditions — and do not have to cover preventive services or maternity care.
In 2018, our nationwide WomenTalk® survey asked women to share their views on a range of health-related topics. Today these results are helping to inform our work, engage our partners, and importantly, keep you updated on health-policy issues that may affect your health, including Access to Care, Affordability, Preventive Care, Chronic Conditions & Policy, Opioid Use Disorder, Medication Safety, and Medical Research & Clinical Trials.
In the news
Most Americans say the government should take action to prevent surprise medical bills. Here is what Congress is doing to fight them. share
Health reform proposals like Medicare-for-all or Single Payer would shift around the health care system and could produce cost savings, but those savings would in part come from the elimination of jobs for insurance brokers, hospital staff, and others. share
Congressional Budget Office experts outlined the complexities of implementing an overhaul of America’s health insurance system. share
Insurance companies sometimes try to cut costs by substituting less expensive drugs for a specific drug prescription. That's raising problems in many cases, and actually causing harm. share
Experienced health care journalists discuss Medicare for all (also known as Single Payer) and why enthusiasm may be decreasing; proposals to increase the age to purchase tobacco; and surprise medical bills. share
Rebates paid from pharmaceutical companies to pharmaceutical benefit managers are increasing, driving up costs for patients, and possibly increasing overall drug spending and prices. share
Websites for people looking for health insurance may lead them to brokers that offer plans that don’t meet ACA requirements, provide less information about the costs and coverage of those non-ACA plans, and which earn insurance brokers more money. share
While California has comprehensive state laws to limit surprise billing from hospitals, patients still get very high surprise bills for emergency care and the state is looking to close that loophole – and create a model for Federal legislation. share
Limiting surprise medical bills – when someone gets a bill for health care that is much larger than they had expected is an area of bipartisan agreement in Congress. share
Prescription drug plans for Medicare that provide rebates back to patients rather that prescription benefits managers or payers have been offered, but not many people bought them. share
Unexpectedly high "surprise" medical bills for having a baby are not uncommon, but also lead women to find a different doctor or hospital for their next child so they can avoid those surprise high costs. share