(USA TODAY) -- Sweeping differences in health care exchange pricing among states and
counties is leading to sticker shock for some middle-class consumers
and others who aren't eligible for subsidies under the Affordable Care
The average prices for the most popular plans are twice as
high in the most expensive states as those with the lowest average
prices, according to a USA TODAY analysis of data for 34 states using
the federal health insurance exchange.
PPOs, the most popular type
of health care plan, carry monthly premiums that range from an average
of $819 a month in the most expensive state to $437 in the least
expensive. Plans on the federal and state exchanges are grouped into
four categories that cover 60% to 90% of out-of-pocket costs. USA TODAY
looked at the pricing of PPOs and HMOs across these bronze, silver, gold
and platinum categories.
The premiums for bronze-level plans are
generally the least expensive, but "the deductibles are simply not
affordable," says Laura Stack, a former financial analyst looking for
full-time work and using her 401k to pay for health insurance. "Many
will not be able to afford the per person deductibles before insurance
begins to pay. What are you really paying for?"
About 4.4 million
people in the individual insurance market are not eligible for the
subsidies and tax credits that can help cover premiums and out-of-pocket
costs, including deductibles.
Insurance brokers and "navigators"
helping people apply for insurance say there are shockingly high prices
for some consumers who aren't eligible for subsidies. Without much
competition in some states and because they know so little about their
new customers, insurers may have priced higher than they would have
After Washington, D.C.'s exchange posted insurers'
proposed rates - something few other states did - three out of the four
insurers refiled lower rates and one of them did it twice.
"don't have to and in most cases they won't compete until you force
them to," says Mila Kofman, executive director of the D.C. exchange and
the former superintendent of insurance in Maine.
carriers are preparing themselves for the worst, so perhaps they will
reduce their premiums, but I doubt they will have enough data to make
that call before 2015," says Rob Nelson, a self-employed property and
casualty insurance broker who was able to keep his canceled policy
•Wisconsin is one of the
top five most expensive states when it comes to average HMO prices, USA
TODAY found. Before subsidies, Wisconsin navigator Brad Gingras says he
was "astounded" by some of the prices that those who don't qualify for
subsidies would have to pay. Every one of the subsidy-eligible consumers
his office has helped was "100% positive" about the plans they got -
once the process was complete.
•Wyoming has the highest average
cost for all of its HMO offerings at $778 a month. Navigator Julia
Heemstra, director of the wellness department at St. John's Medical
Center in Jackson, Wyo., had a similar experience. She spends a lot of
time talking to Wyoming residents to help them understand why health
care costs are so high in a big state with the smallest population in
•Texas ranks as one of the most affordable states for
both PPO and HMO offerings, with average monthly premiums of $200 to
$250. Still, Wichita Falls insurance broker Kelly Fristoe says his
individual policy customers are finding premiums are 30%-50% higher for
next year. Lately, he's been enrolling people in the exchange who were
in the state's high risk pool. These people have found the exchange
plans cost slightly less or the same as their old plans. Only about 20%
are eligible for subsidies. Others making above 400% of the poverty
level "are just angry when they do have to make a change because for the
most part they are going to have to pay more money," Fristoe says.
Webster, 62, of Kitty Hawk, N.C., says his health insurance premium
for a Blue Cross/Blue Shield plan is going from $401 a month to $747.
His old plan was canceled, and the best plans the insurer could offer
both on and off the exchange cost the same. Dare County is one of the
18% of counties with just one insurer on the federal exchange, USA
TODAY's analysis shows.
Department of Health and Human Services
spokeswoman Joanne Peters says most consumers will get a better deal on
the exchanges, both in price, out-of-pocket costs and coverage.
we know a small slice of consumers may not be eligible for a plan at a
more affordable price," she says. "That's why we are allowing insurers
to continue offering plans that would have been canceled for another
Wendy Wolf, 64, who isn't eligible for a subsidy, saved $10
a month and got better coverage with a plan on the federal exchange
after her Blue Cross/Blue Shield plan in Philadelphia got canceled. Her
co-payments are lower, she has no deductible and she appreciated the
fully covered preventive care in the new platinum plan, which costs
$1,022 a month.
"I'm much better off with my new policy," she says.
complaining about pricey exchange options were probably benefiting
before from what's known as "risk segmentation," says John Holahan, a
fellow at the Urban Institute's Health Policy Center. That is, healthy
people who were buying individual insurance got a break on premiums
because they were grouped with other healthy people when premiums were
set. The Affordable Care Act prohibits this kind of "medical
underwriting," because it penalizes people who are older or in poor
health. States have some leeway to limit variation further, but
insurance rates for older people are generally capped at three times
that of younger adults.
The ACA is " trying to say we want to pool
risk and share the costs as broadly as we can so that everyone is
protected by affordable insurance throughout their lives, at times when
they think they will be healthy and at times when it turns out that they
are sick," Holahan says.
People who get insurance through their
employers - most workers do who work for companies that are
self-insured, as most big companies are - are used to being grouped in
pools where they may be paying more or less than they would have been
individually because the cost of their employer insurance is based
largely on the health of the others at their company, Holahan says.
who worked on Massachusetts health care law, says the state had already
prohibited both pre-existing conditions exclusions and limited medical
underwriting before its overhaul in 2006.
Holahan says, "It wasn't as big of a step for them."
three-quarters of people buying insurance in the individual market - or
10.8 million people - are eligible for subsidies because of their
incomes, according to a report out Thursday by the advocacy group
Families USA. That includes individuals earning less than $46,000 and
families of four earning less than $95,000.
The group estimated
that 1.5 million people won't get subsidies. That doesn't count people
who buy health insurance only for a few months, such as people changing
jobs. Adding them boosts the total to 4.4 million.
lives in The Woodlands, Texas, has been shopping for a plan she can
afford on the federal exchange. She says the ACA has a communication
problem when it comes to people in the middle class.
"This is really for catastrophic care, but I'm not seeing it sold in that manner to the American public," she says.