Why Many Are Not Accessing State Insurance Exchanges: Have They Been Misled by Sound Bites or Political Ideology?

In prior "Health Care Reform" columns, the power that media sound bites have to mislead has been discussed. Media can also provide insights when investigative reporting provides information not easily accessed by the public. Television and radio shows have been providing running tallies on numbers of citizens visiting the state insurance exchanges seeking access to health insurance, and the numbers do not look good, are not meeting minimal expectations, and do not bode well for participating health insurers and persons who are uninsured. Many are qualified to gain insurance and for subsidies to pay part or most of the premiums; however, they are not going to the exchanges. One has to wonder why.

Last year, Steven Brill, a Time magazine reporter, wrote a lead article, "The Bitter Pill: Why Medical Bills are Killing Us" (Brill, 2013) and now also writes a column that appears regularly in Time. The January 27, 2014, column titled, "Hate Obama, Love Obamacare," is not only provocative, but provides insights that we as health care providers may not be aware of and that can and should be shared with colleagues, patients, and families cared for in ambulatory settings, especially those who may need to access health insurance. Steven Brill interviewed Stephanie Recchi just after the launch of Healthcare.gov. "I don't think Obamacare will help us. I don't want anything to do with it…I hear a lot of bad things about it — that it doesn't cover preexisting conditions, and it's too expensive" (p. 18).

This article presents the case of the Recchi family faced with a catastrophic diagnosis of cancer for Stephanie's 42- year-old husband, a small business owner and the father of their four children. He and his family had health insurance purchased for $469 a month. They found when they went to MD Anderson Cancer Center in Houston, Texas, the hospital demanded $83,000 in advance just to develop a treatment plan and to administer his first transfusion and laboratory tests. Their insurance was inadequate in this case because of his diagnosis (it covered only $2,000 a day in the hospital as an inpatient, which barely covered the first round of blood work at MD Anderson).

The Recchi family's experience of being essentially uninsured and facing catastrophic out-of-pocket expenses drove Stephanie to visit HealthCare.gov; however, "It kept freezing and crashing." This aptly describes the failed launch in the face of desperate need for health care insurance on the part of many. But with recent improvements in the HealthCare.gov website, and through consultation with an insurance broker, the Recchis have found profound solutions to their plight.

One insight in this article was the availability of advice provided by an insurance broker; this is essential for those who are uncomfortable with on-line data gathering, decision making, and filing. Insurance brokers are paid by insurance companies and are responsible for explaining the options for both coverage and costs to patients and families. The insurance broker takes a patient to the online state exchange and walks them through the steps. Everyone needs assistance deciphering the four levels of coverage — "Bronze," "Silver," "Gold," and "Platinum" — each with multiple variations on premiums, co-pays, coinsurance, and deductibles. In addition, state exchanges have enrollment assistants who work with consumers and are trained and certified by officials operating the state exchanges. Information such as this should be shared with ambulatory care patients, especially those who have experienced challenges when trying to use state insurance exchanges.

Other insights offered in the Time article are the ways that insurers have tried to limit their costs. They often provide limited options for provider networks, hospitals, doctors, and providers; insurance companies often choose networks and providers who offer "cost-effective" pricing. This could mean there will be differences in the quality of care offered. Health care providers will often be asked questions about whether they will still be in a network the patient may choose. This is a question that an insurance broker or assistant can answer, and patients should be referred to them.

The Affordable Care Act (2010) originally had provisions that expanded the income limits for persons/families qualifying for Medicaid. This provision was contested, and the Supreme Court decision allowed individual states to make a decision to opt in or out of expanded Medicaid where the Federal government would subsidize all but the administrative costs. What is often not understood is that Medicaid is a state program, so if a patient or family has Medicaid in one state and tries to access care in another state, he or she cannot unless moving into the state as a resident. Further, several states decided not to expand Medicaid, so there are often marked differences in income requirements between the states that expanded Medicaid and those that did not.

The reality is that health care systems in the United States are complex, and patients have traditionally had challenges navigating within it. One of the solutions to this situation has been the creation of a navigator role to assist patients trying to access care. What was missed in the planning for accessing insurance as part of health care reform was not only the under-estimation of the complexity of the online exchanges, but also more consideration should have been given to the need for navigators to assist with understanding and making decisions about types of insurance needed, qualifications for subsidies, and the challenges implicit in documenting income levels. Case studies, such as the one provided by Brill (2014), will surface over time, and these will provide an accurate picture of the complexity of challenges and insights as to possible solutions.


Brill, S. (2013). The bitter pill: Why medical bills are killing us. Time. Retrieved from http://time.com/198/bitter-pill-why-medicalbills- are-killing-us/

Brill, S. (2014). Hate Obama, love Obamacare. Time. Retrieved from http://time.com/908/hate-obama-love-obamacare

Sheila A. Haas, PhD, RN, FAAN, is a Professor, Niehoff School of Nursing, Loyola University of Chicago, Chicago, IL. She can be reached at shaas@luc.edu