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A little knowledge about health insurance can be a dangerous thing

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At a press conference called by U.S. Rep. Debbie Wasserman Schultz Thursday at mid-town Miami's Borinquen Medical Centers, an example of Obamacare's benefits to people earning less than 400 percent of the federal poverty level unraveled before television cameras.

Pointing to South Floridians whose health insurance situations had benefited from the new health reform program, Wasserman-Schultz introduced Miriam Romero, 61, the first person to be enrolled by Borinquen's Certified Application Assisters. Romero, who retired from her Miami-Dade County job of 29 years as a pre-kindergarten teacher, had been uninsured since August because she couldn’t afford a $350-a-month health plan when her COBRA coverage ran out. Assisted by a Certified Application Counselor, she chose the lowest-cost plan offered in Miami-Dade's healthcare marketplace for someone her age: a high-deductible Bronze HMO plan costing $136 a month.

But Romero hadn't realized when she signed up for the plan that the $136/month premium was only the beginning. When she learned that she would need to pay for all of her medical costs until she reached the plan's deductible, and share 40 percent of her medical costs until she reached the out-of-pocket maximum, she visibly blanched. "I might cancel it," she said.

Romero, who had never bought her own health insurance and has a pension that nets only about $13,000 a year, is an example of the people Obamacare is targeting through assisters like the one who helped Romero. Borinquen, a Federally Qualified Health Center serving the uninsured, hired its CACs with a $258,243 grant from the Centers for Medicare and Medicaid -- one of a dozen such health centers in Miami Dade to receive an award. 

But while many CACs have strong public healthcare backgrounds, they're not so experienced with private health insurance products. It is one, but not the only, possible reason that Romero enrolled in a plan that might not fit her budget. 

On the one hand, the feds wanted to protect people like Romero from the market biases of insurance agents; the reason agents who are certified to sell subsidized health plans can only do so on the online marketplace. But, like computers, which didn't become a retail product overnight, insurance requires an education process that some CACs may not be able to provide. Romero's case suggests that the insurance industry, which has launched a campaign touting its agents' expertise, has a point.

To make matters more challenging, Navigators and CACs haven't had much time o to study the health plan products. 

Romero’s healthcare choice also also reflects a little-known feature of the ACA that requires companies who sell plans on the healthcare marketplace to include a small percentage of health centers like Borinquen in their networks. While Romero was attracted to the plan's low premium, it's also true that the plan features the health center in its provider network.

Both CMS and Florida legislators took pains to make sure that federal Navigators -- organizations that also received federal grants to understand and enroll in health plans -- would not advise people on specific insurance products. Nor do they or the CACs receive a commission when someone enrolls in a health plan. But while Navigators were expressly prevented from having ties to the insurance industry, little has been mentioned about the possible bias of CACs, who work for health centers involved in some carriers' provider networks. 

In Romero's case, it seemed clear that inexperience, not bias, may have led to an unsuitable health plan choice. That raises perhaps the most important wrinkle in the unfolding health law implementation: Cost. 

To keep plan prices low, insurance companies have weighted their profit margins toward the provider networks and cost-sharing. Agents inside the business who attended information sessions with carrier representatives, say some companies targeted their Bronze plans with the lowest premium prices and narrowest networks to people with low incomes who would be motivated to look at these products first. 

That seems to have been what happened in Romero's case, and why inexperienced health insurance shoppers need financial, as well as healthcare, knowledge to make the best choice. 

 

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