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.
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