Medical Debt Still a Problem Under Health Law — Despite Protections

Elizabeth and Britt Harmon struggled for years to have a child, and were thrilled when their son Orin was born in February 2013. But they were unprepared for the medical problems that then upended the Brooksville, Maine couple’s lives.

Orin was born with pulmonary stenosis, a heart condition, and severe asthma.  He required constant care, including frequent trips to the hospital and medications that cost hundreds of dollars. The Harmons had insurance through Britt’s job at a plumbing company, but it covered “maybe half” of their child’s medical expenses, Elizabeth said.

Elizabeth Harmon with son, Orin, who is just a few days old in this picture. They are resting at home between medical appointments. (Photo by Britt Harmon)

Elizabeth Harmon with son, Orin, who is just a few days old in this picture. They are resting at home between medical appointments. (Photo by Britt Harmon)

Then, Britt’s employer dropped insurance as a benefit at the end of 2013; he lost his job in June. The family scrambled to find coverage but went three months without any before qualifying in July for MaineCare, Maine’s Medicaid program for low-income people. By then, the Harmons had accumulated thousands of dollars in medical debt, Elizabeth said. They’re still working — with the help of a local non-profit organization — to pay it off.

“I’ve sold furniture out of my own house to try to pay off some of the bills,” she said. “There were so many bills, it was impossible to keep track of everything.”

The federal health law was intended to keep a surprise illness or injury from bankrupting Americans. It authorized states to expand eligibility for Medicaid and created online insurance markets where others without employer coverage can buy plans, with federal subsidies available. When calling for the law’s passage, President Barack Obama declared people shouldn’t “go broke because they get sick.”

In 2013, medical debt was the largest cause of personal bankruptcy – 1.7 million people lived in households experiencing bankruptcy because of health costs. But the law hasn’t eliminated the problem. Many states haven’t expanded Medicaid and even those with insurance can rack up big bills, a problem exacerbated by the growing number of plans with high deductibles.

The health law brought regulations to limit for the first time the cost-sharing in plans. An individual plan sold on an exchange can’t include out-of-pocket costs greater than $6,600. In practice, the average deductible, or portion a consumer must pay before insurance kicks in, varies based on how expensive a plan is. But the regulation still only applies to providers and specialists specified by the plan as “in-network.” The narrower the network, the more vulnerable consumers are to incurring medical debt by visiting unapproved doctors or hospitals.

The health law wasn’t supposed to eliminate health care cost-sharing; on the contrary, people are expected to have “skin in the game.” So there will always be a risk of incurring costs greater than people can afford to pay, said Melissa Jacoby, a professor at the University of North Carolina-Chapel Hill and an expert on debt and credit.

“Some of the forces that were in play prior to the passage of the Affordable Care Act are still in play,” said Mark Rukavina, who founded Community Health Advisors, a group that advises providers on how to comply with federal regulations. Inflation and rising health care costs – especially compared to wages – make care more expensive and weren’t necessarily addressed through the health law.

Still, some numbers suggest a decline in people facing medical debt. About 64 million Americans struggled to pay medical bills in 2014, according to a survey by the Commonwealth Fund – that’s a drop of about 10 million since 2012. Experts have celebrated the decline but cautioned that high-deductible insurance plans could put a damper on those changes.

Of the 64 million the authors said were struggling to pay for care, 38 million – or 59 percent – were insured the whole year.

There’s been some improvement: The same report found 29 percent of the insured had medical debt or difficulty with medical bills, a drop from 33 percent in 2012 – while the pool of insured adults grows larger. But analysts cautioned that, absent a significant change in industry or policy, even this group will likely continue to face the prospect of medical debt.

Deductibles keep growing. Last year, work-sponsored insurance plans had an average deductible of about $1,200 – in 2009, the average deductible was $826. And this year, the silver plans sold through the federal marketplace require people to pay on average more than $2,500 or about $3,500 before they get coverage. Whether it is the higher or lower amount is determined by whether the plan groups medical visits and drug costs in a single deductible or two separate deductibles. Bronze plans, known for being cheaper but less generous, have average deductibles of about $5,300.

“There’s wide acknowledgement in the health care community that high-deductible health plans in general are part of the problem,” said Jessica Curtis, who directs the Hospital Accountability Project at Community Catalyst, a nonprofit group that advocates on behalf of health care consumers.

But there’s no incentive to curb cost-sharing. And insurers have no reason to widen the so-called narrow networks that posed problems for the Harmons, who often needed to travel to Boston for asthma treatments unavailable in rural Maine. They paid for those trips out of pocket until Medicaid relieved them of some bills, Elizabeth Harmon said.

But other bills remained. And if the couple had moved elsewhere to find work, which they considered, they feared the hospital would seize the money made on the sale of their home, Elizabeth said.

“I have a stomach ulcer from stress and not being able to eat,” she said. “I was unable to sleep at night because I was afraid they would put a lien on our house.”

To make ends meet, Britt found work as a lobsterman, and then started an independent plumbing business. Meanwhile, Orin’s health has improved and Elizabeth says doctors say his treatment regimen could soon be scaled back.

Still, their financial worries highlight another continuing concern. Even with the health law in place, efforts to regulate how providers can collect on patient debt remain limited. For instance, hospitals and doctors, Curtis said, can still obtain judgments, garnish paychecks and go after people’s assets, including their homes.

The federal government in December rolled out a rule intended to curb these tactics, requiring that, by 2016, nonprofit hospitals actively publicize financial assistance policies. But since hospitals determine who qualifies for aid, the rule is “like Swiss cheese,” Curtis said.

For-profit hospitals won’t have to comply, and unaffiliated outpatient facilities could remain essentially unregulated in terms of how they collect on debt.

Meanwhile, the federal Consumer Finance Protection Bureau has taken preliminary steps to craft rules on medical debt collection. But those would take time to write, and probably wouldn’t go into effect for more than a year, Wu said.

Meanwhile, families like the Harmons get by – partly in thanks, Elizabeth Harmon said, to the doctors and advocates who helped Orin get the care he needed. His health has improved enough that for the first time, doctors are considering taking him off some medications. Yet the couple continues to seek local aid and charity care to keep their bills in check. “We’re not ahead of the game,’’ Elizabeth said, “but we’re keeping our heads above water.”

Categories: Cost and Quality, Insurance, Syndicate, The Health Law