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
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
As policy makers seek to find ways to expand access, some Federal officials are touting Medicare-For-All, while some state officials are exploring an option to get more people into state Medicaid programs. Both ideas have supporters and detractors. share
A federal district court ruled that the ACA is unconstitutional raises doubts (again) about the law, even as more people benefit and premiums for ACA plans have stabilized. Listen to the podcast. 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
Patients with cancer face not just the challenges of their illness and the treatments, but also high costs for care, confusing insurance rules, and often chaotic processes at insurance companies. share
A federal district court ruled that the ACA is unconstitutional raises doubts (again) about the law, even as more people benefit and premiums for ACA plans have stabilized. share
Women and men can experience sexual problems as they get older and there are FDA approved medicines that can help. However, despite the medical need to treat conditions such as vaginal dryness, insurers may balk at paying for those medicines. share
States are looking at laws to prevent patients from receiving very costly surprise medical bills from out-of-network providers sending patient bills under a practice called balance-billing. share
Congress’s must fix the impending "out-of-pocket cliff" for the Medicare Part D prescription drug program that could severely harm 44 million Americans. share