So you got insurance. Will it help?

As the 2015 push for health-insurance enrollment winds down, the next challenge grows ever clearer:  Insured people who can't afford medical care.

The New York Times Sunday Review carried an article titled  "Insured, but Not Covered."  Reporter Elisabeth Rosenthal explores trends in insurance and health care that are leaving people with insurance unable to find doctors or pay bills.

Her conclusion:  While the Affordable Care Act has brought coverage to roughly 10 million Americans and eliminated  "some of the more egregious practices of the American health insurance system that left patients bankrupt or losing homes to pay bills,"  the law has also adopted policies that "may in some ways be undermining its signature promise:  health care that is accessible and affordable for all."

A key culprit is the boom in high-deductible policies,  which allow employers and private buyers to reduce premiums by agreeing to much higher out-of-pocket costs.

For instance,  HealthSherpa recently sent along an analysis of  14,000 North Carolina health insurance purchases made on the company's web site,  which provides an alternative path for buying subsidized plans on the ACA exchange.  Those buyers had an average household income of about $20,400 and bought policies that averaged $70 a month for the buyer,  with the government kicking in an average of $381 a month.

But the average deductible per enrollee was $3,969 and the average out-of-pocket max was $5,745.  Can you imagine anyone making less than $21,000 a year being able to save $4,000 to $6,000 to cover those costs?  Reality is,  even paying a couple of hundred dollars may be daunting enough to discourage people from going to the doctor's office.

A recent report from The Commonwealth Fund showed that the number of people skipping care because of costs declined in 2014,   the first time since the question was added to the fund's health insurance survey in 2003.  But while the numbers fell significantly compared with 2013,  the year before the ACA took effect,  the report estimates that 66 million Americans,  or 36 percent of adults, still skipped an office visit,  test,  treatment or prescription because they couldn't afford it.

ontinue reading the main storyBut by endorsing and expanding the complex new policies promoted by the health care industry, the law may in some ways be undermining its signature promise: health care that is accessible and affordable for all.

Healthy, wealthy and worried

Even people with health insurance who call themselves financially secure worry that they can't cover their out-of-pocket costs if a medical emergency strikes, a new survey from eHealth shows.

Two-thirds of 1,000 insured adults polled by Wakefield Research described themselves as financially secure,  yet half of that group said they would struggle to meet their deductible in case of an expensive crisis. The trend was even more pronounced among adults ages 25 to 39,  who described themselves as wealthier,  healthier and more optimistic about their finances than older counterparts. But 69 percent of the young adults doubted they could afford their deductibles.  Confidence about out-of-pocket costs was highest among those 55 and older.

Out-of-pocket costs are rising as employers and people who buy their own insurance try to rein in premiums.  eHealth's price index shows what many others have reported:  People are trending toward plans with higher deductibles this year.

eHealth, an online insurance exchange,  launched its Coverage Satisfaction Index to track consumer opinions about coverage,  health and finances  (read an overview of the December poll here).  The sampling was designed to be representative of the nation,  though the South accounted for 37 percent of those polled  (compared with 20 to 22 percent for the other three zones).  About 35 percent reported income of  at least $75,000,  with the rest evenly divided between those in the $35,000 to $74,999 bracket and those earning less.

Some of the results:

*Eighty-six percent described themselves as at least somewhat satisfied with the value of their current health plan,  with 40 percent saying they are very satisfied.  The poll found no difference among those who bought their own coverage and those who got it from an employer,  but those with such government-funded plans as Medicare,  Medicaid and military insurance topped 90 percent satisfaction.

*One-third of men and 38 percent of women said they've skipped medical procedures,  such as exams and immunizations,  to save money.

*Opinions are split on the impact of the Affordable Care Act on their health benefits,  with 32 percent saying it's positive,  28 percent negative and 40 percent saying there's no effect.  Those under age 40 were most supportive of the ACA,  with 45 percent citing a positive impact.

*When asked to name their top three financial fears,  "an expensive medical emergency"  topped the list  --  though that may be no surprise,  coming after a long list of questions about the costs of care.  Asked whether they spent more time thinking about the cost of their health insurance or their cable package,  63 percent said insurance and 37 percent said cable.

Who's taking biggest hit on workplace coverage?

I'm hearing a growing sense of frustration from people who pay a lot for workplace health insurance,  and a new study from The Commonwealth Fund confirms there's good reason.

The state-by-state analysis of employer coverage shows that residents of the Carolinas pay a steadily-growing portion of their income for premiums and deductibles. And in the South,  where median wages are lower,  those rising costs take a bigger bite,  the study concludes.  (Read the report here and check interactive state maps here.)

Especially hard hit are North Carolina employees with family coverage.  While costs for employee-only coverage here are in line with national averages,  family coverage costs more in North Carolina.  And premiums for family coverage are growing at just over 10 percent a year during the past three years,  compared with 5.9 percent nationwide and 7.2 percent in South Carolina.

Folks I talk to often blame Obamacare.  They're paying taxes to subsidize premiums and deductibles for people who don't have workplace coverage.  But employees who are eligible for coverage that meets the standards of the Affordable Care Act can't tap into those subsidies themselves,  even though they may be paying sums that seem far from affordable.

Researchers from The Commonwealth Fund conclude that the relationship between rising worker costs and the ACA is complex  (the fund is a private foundation that "underwrote a considerable part of the research" underlying the act).  Some aspects of the act,  such as allowing young adults to stay on parents' plans until age 26 and requiring full coverage of preventive care,  could drive up costs,  the report says.  But overall premiums were growing much faster in the years before the ACA kicked in than in years since,  the report notes,  indicating that such costs  "have been easily absorbed in insurance markets."

In fact,  the study indicates that North Carolina employers have seen a more dramatic slowdown in premium growth than counterparts across the country.  For instance,  N.C. premiums for workplace plans were growing at 5.6 percent a year from 2003 to 2010,  compared with 5.1 percent nationally.  But from 2010 to 2013,  N.C. premiums have risen by only 1.6 percent a year,  compared with 4.1 percent nationally.

So why doesn't this ring true to workers?  Because,  as I and many others have noted before,  employers are passing along a bigger share of the costs,  forcing their staff to cover a bigger share of premiums and/or higher out-of-pocket costs.  For instance, that 1.6 percent annual growth in the overall cost of a single-person workplace policy in North Carolina translated to a 4.7 percent annual increase in the employee's share.  And while the overall cost of a family policy in North Carolina has grown only 3.3 percent a year since 2010, the employee's share has risen by 10.3 percent a year.

"The key question is how to slow health care cost growth in a way that benefits middle class and lower-wage working families  --  that is,  keeping premium growth in check without eroding benefits,"  the Commonwealth study concludes.  "This will likely require concerted efforts that span the private and public sectors.  The challenge to policy leaders will be to pursue reforms that improve the quality of health care,  rein in cost growth,  and ensure that savings are shared with patients and families across the income spectrum."