This month, millions of Americans will receive letters from their employers explaining the state health insurance marketplaces (formerly known as exchanges). I know because my job required me to send the letter to a sizable number of people.
If past experience is any guide, at least two-thirds of the people who receive the letter will glance at it, be confused and come to my office with questions already answered in the letter. The remaining third will be split between people who threw it away without reading it, people who read and understood it, and people who didn’t read it, didn’t understand it and are confused and/or angry. People have heard so much disinformation that I will spend the rest of the month and probably a good chunk of October debunking lies, correcting misinformation and calming terrified people.
The Republican campaign of healthcare reform disinformation has been wildly successful for a couple basic reasons. Far too many people have minimal to no comprehension of their health insurance. Most people know all it takes is a single serious illness and their financially ruined. And a great many Americans are financially precarious in the first place, holding on by their fingernails to economic stability, forget getting ahead.
A few recent conversations illustrate these realities:
An employee came to my office needing to enroll in the insurance plan. The employee waived insurance during open enrollment which means they have to meet fairly strict guidelines governing eligibility – new hire, loss of other coverage, major life changes – and a very strict timline to notify the insurance carrier – no more than 30 days since the change. This employee has been without insurance since their spouse was laid off – almost a year ago. The prior weekend, they had a medical emergency with a family member. Suddenly faced with thousands of dollars in hospital and doctor bills, the employee panicked and realized they needed insurance. Of course, even if they could enroll, it would be too late – the services were provided before they had coverage. The soonest the employee can get insurance is January, through the marketplace. The employee is frantic for coverage right now.
Another employee arrived in my office and asked, “How am I supposed to get insurance starting in January?” I asked, “What are you talking about? We’re going to keep offering health insurance.” This employee was told that as of January 1, 2014, companies will no longer offer insurance and everyone has to buy through the state marketplaces. This employee has a child with expensive medical needs. Having been told that Obamacare means companies won’t offer insurance anymore, the employee was nearly physically ill at the thought of being without coverage and in a near panic about the costs – for the monthly premiums paid to our plan, no affordable family coverage exists. I explained our insurance plan would continue and we talked about the marketplaces.
In the last month, I’ve spent more and more time on health insurance questions, most of that time correcting misinformation and disinformation. It’s not just employees who I’d expect to have not paid attention – even employees I thought were more informed and astute have are confused.
As I unwrap these these conversations, a couple themes emerge.
First, very few people actually understand health insurance. Because I have to administer it, I’ve deliberately kept the insurance plan at my employer as simple as possible. Preventive care is covered 100%. Everything else is the employee’s responsibility until they meet the deductible. That means if you sprain your ankle or get an infection or need a prescription, you pay the cost of treatment and the cost of the prescription. Once you meet the deductible, the plan pays 100%. Our employees cannot wrap their heads around that. I regularly have to explain, “There’s no copays. Just meet the deductible . . . No, treating a sprained ankle is not preventive . . . no, insulin for your diabetes isn’t preventive . . .” Given that the plan hasn’t changed in three years, these questions demonstrate to me that lots of people don’t think about insurance until they have to.
Second, people are justifiably worried about health care and the cost of health care. For too many famlies, the thought of a $10,000 medical bill is horrifying; even if they are only responsible for a few thousand dollars of that bill that few thousand dollars spells financial ruin. Something as simple as a trip to the urgent care clinic to treat a sprained ankle or ear infection can be a financial burden. Some family budgets are stretched by the premiums – any thing over and above those premiums breaks the budget. People are aware of these realities and they are overwhelming; they avoid thinking about them. A major illness of medical crisis can ruin a family financially.
Third, many people are vulnerable to disinformation about their health care because they are already barely hanging on and their health insurance is cold comfort against the possibility of disaster. The thought of losing their health insurance terrifies them. They’re susceptible to fear-mongering because they’re already afraid. I’ve had employees break down in my office when the bills start rolling in and they realize that just paying their portion of the costs mean moving to a cheaper apartment or going without desperately needed new clothing. The consequences of being without health insurance are devastating, but even with health insurance the costs of illness are ruinous.
These forces put families under tremendous pressure. The tendency to not think about insurance until you need it means many people are woefully ill-informed any way. The prospect of tens of thousands of dollars in medical bills paralyzes people. They spend their days hearing lies and disinformation, they get garbled information and often they just don’t have the energy to sort the truth from the lies.
At the end of the day, people are getting these letters and suddenly all these issues are unavoidable. They have to think about insurance, they have to ponder implications they don’t want to ponder and they have to worry about owing someone money they don’t have. The combination of misinformation, disinformation and panic become the problem to be solved. In a few months when people realize it wasn’t a big deal, then, well, things will be fine. I don’t know what will ultimately happen. People’s fear of losing what little protection they have, however, seems to be motivating most of our debate around healthcare reform. Fear and uncertainty are the enemies.