By Sharon Adams

I am fortunate that I’ve always been insured. It has shaped my experience with health care access and how I move through a care experience. And it has certainly influenced the expectations I have of my health care providers and the system in general.

Sharon Adams

Not only have I utilized the health care system, I’ve also worked in the industry a very long time. Even with all that experience, it can still be difficult for me to navigate. It’s hard for me to imagine how overwhelming it must feel as a newly insured person or family learning to access a system of care in a new way.

If it’s true that, as attributed to Dr. Don Berwick or W. Robert Deming (depending on the source), “every system is perfectly designed to get the results it gets,” then how do we best help patients and providers move into a new era of health care visa vie the Affordable Care Act?  While we are certainly experiencing some early wins in expanding coverage and enhancing coordination, we’re also beginning to understand the realities of what we’re creating. There are new challenges… some of them unanticipated and others known but now magnified.

ClinicNET’s job is to advocate for and enable our affiliate safety net clinics to optimally care for low income, under-insured and uninsured Coloradans. That means we talk (a lot) to Community Safety Net Clinics (CSNCs) about the issues that are emerging as health care reform is implemented. We know from these conversations that the law fails to fully address some fundamental cost and coordination problems — problems that may prevent patients from receiving affordable, accessible and comprehensive care.

Among the emerging issues are:

Difficulty navigating the system

Many Coloradans fortunate enough to get coverage through Medicaid expansion or Connect for Health Colorado have never been insured or have been uninsured for many years. These patients do not have the experience to navigate incredibly complex insurance plans and often are not sure how to utilize their new benefits or where to go to receive care.

Unaffordable premiums in high-price markets

Many across our state are still unable to afford insurance in spite of the insurance marketplace and federal subsidies. Colorado’s resort counties in particular have experienced higher costs of care and high premiums, leaving many unable to afford coverage or qualify for subsidies.

Confusing and potentially costly 90-day grace period

The ACA 90-day grace period for paying premiums is resulting in additional challenges for both patients and providers. According to the law, any health care service rendered during the first 30 days has to be covered. If a premium payment has not been made, a health plan can refuse to pay providers for care delivered during the remaining 60 days.

The ambiguity of payment during the 60-day period raises concern about the eligibility verification process for providers. It’s also confusing for patients who may be asked to make a cash payment up front for care if the insurance company cannot guarantee coverage.

High-deductible plans and expensive co-pays unaffordable

Clinics are finding that patients with insurance are not always able to afford the high deductibles and co-pays associated with their plans. Safety net clinics accustomed to offering affordable care are especially struggling with this issue. A previously uninsured patient who received care on a sliding fee payment scale now might be encouraged to pay full price in order to whittle away at their high deductibles. Being insured should be a relief, not a cause of extreme financial stress.

Newly insured no longer qualify for medication assistance

Through prescription assistance programs, uninsured patients are able to get their medications at little or no cost. Newly insured patients no longer qualify for this kind of medication financial assistance. For patients on costly medications where generic options are not available, what was $10 in medications monthly through assistance programs may now be $500 or more per month.

And so we wonder … when faced with high deductibles, co-pays and medication costs, are patients thinking twice about whether their new insurance is affordable long term? Is taking a penalty for not having insurance likely to cost far less than these high costs associated with being insured?

We acknowledge these emerging issues and yet the order of the day is to meet the health and health care needs of all Coloradans. Kudos to CSNCs and their community partners in redoubling efforts to ensure everyone has access to care, robust patient education, care coordination and patient navigation.

Sharon Adams is executive director of ClinicNET. Contact Sharon at [email protected] or visit ClinicNET.org for more information.