When I moved to NY, I had to quit my job. Even though my employer, the largest health plan in Hawaii, wanted to keep me on, they had a firm policy that they would not employ out of state individuals. What that meant is that I was thrust into the world of independent contracting. A new and scary place that forced me to withhold my own taxes and eventually select my own health care.
Since I worked in the field, I knew that my Hawaii based employer coverage was very, very rich. I had a low (maybe no) deductible and my benefits were set by the state under the historic 1974 Prepaid Health Care Act. I did some research and knew that my Hawaii based COBRA plan would be comparably expensive in premiums but offer a generous set of benefits. Since my employer is part of the Blue Cross Blue Shield network, even though I was in NY, I could still readily access participating providers. The cost of the premiums for my son and I was my second highest single expense, after our rent, but it was worth it in peace of mind for me.
Unfortunately COBRA is only available for 18 months and as that exhaustion date approached I began to shop for plans on the NY state health exchange. I basically had to shop for individual coverage after being on employer based plans my entire life. NY does not participate on the federally facilitated marketplace (FFM) to sell individual coverage but their state exchange generally operates under the same requirements. I had a strong impulse to sign up for another Blue plan but the closest hospitals to me were not in the network. That seemed foolish. I found another carrier that offered plans that had both my and my son’s primary care physicians in network. I made the choice. It felt like jumping off a cliff. The cost was about the same as the premium cost for our COBRA plan but I quickly came to learn that all coverage is not equal.
Under my Hawaii health care plan, I pretty much had first dollar coverage. What does that mean? It means that whenever I went to the doctor, I was only responsible for my copayment or coinsurance. When I think that I used to consider that to be a lot of money, it is pretty amusing. I quickly realized that there were not many services that were provided to my son and I until we had met our deductible. If we went to see our primary physician, we only paid our co-pay (some services are provided before the deductible is met). But when I had a threatening mole removed at the dermatologist, I was charged the amount that my plan would have paid if I had met the deductible. It was around $250.00. I received the bill and was so confused. This had never happened before. It was my welcoming to the wonderful world of insurance and, how, unfortunately, it works for the majority of people in this country.
In addition to the out of pocket shock I have experienced here on the mainland, I have also dealt with the fact that I live in a rural area and finding providers (aside from our PCPs) has not been a simple prospect. I could go on for a very long time about the numerous calls I made to my plan to try to find an ENT somewhere in my area. It was a giant fail and I ended up having to drive an hour up island to see someone. And of course, I had to pay the cost of the visit because I had not yet met my deductible.
Today, I tried to make a dentist appointment for both myself and my son. There are numerous dentists in my town but none of them take our insurance. I tried to get him to see a pediatric dentist but was told that in dentistry, once you hit thirteen, you are no longer a pediatric candidate (he is sixteen). The provider list looks long and promising on the website, until you realize that most of the dentists listed are affiliated with one of the two Federally Qualified Health Centers (FQHCs) in the area. I finally broke down and called one and the woman told me that the earliest appointment she had was in October. I thanked her and hung up.
I pay a lot in premium dollars for coverage that does not seem to offer much coverage. Because I work in the industry, I know that I am now eligible for a subsidy (thanks President Biden!!) to decrease the amount of premiums that I pay. Because I work in the industry, I know that currently there is a special enrollment period and that I could change my plan tomorrow. I could change it to drop my paltry dental coverage and pick up a stand alone dental plan that includes dentists where I live with appointments in this season.
The thing is, is that it should not be this way. It should not be this hard. This difficult. This confusing. If the FQHC was the only place that I could obtain dental services, I would be screwed. I would be waiting until the fall just to see a dentist. Despite all of the issues that I have had accessing care, I know that I am lucky. I have the time and the resources to try to work around what is truly a broken system of care. Most people don’t. It’s time to level the playing field. It’s time to stop leaving people behind. We can do this. And I hope we do.