Westy Byrd buys the cheapest health insurance plan she can. And next year, even that might be too much.
Kate Vehrs has already struggled to find a doctor, and as insurers drop out of the individual market, her search for someone who can provide her with long-term, consistent care has become nearly impossible.
About 51,000 others in the Richmond area — and more than 400,000 across the state — have a million other worries.
They all boil down to one key question: Will I be able to get the health care I need next year?
In Richmond and Chesterfield, Hanover and Henrico counties, there will be only one option on the Affordable Care Act’s marketplace next year, through the national insurer Cigna. Its premiums are set to increase by an average of 50 percent, or an extra $400 on an $800 plan, for example.
And unless there’s a change in the next couple of months, two of the three largest health care providers in the region, Bon Secours and VCU Health, could be shut off from those patients.
Cigna’s plan is an HMO, which means it only pays for visits to doctors in a pre-approved network of doctors and hospitals. And Cigna historically has contracted exclusively with HCA Virginia.
In a statement, a Cigna spokeswoman confirmed that the insurer is still planning to work with HCA for its 2018 individual market plans.
VCU Health saw more than 5,300 individual patients last year through the two largest plans sold on the exchange, from the insurers Anthem and Aetna. Of those, 3,350 reside in counties or cities that will only have Cigna as an option next year.
The health system anticipates that the loss of revenue would be more than $28 million, according to a spokeswoman.
Aetna was the primary way patients gained access to Bon Secours through the individual market, said Tony Herbert, Bon Secours’ vice president for managed care.
There were about 18,000 individuals under that plan assigned to Bon Secours primary care doctors, he said.
Herbert called the loss of those patients “the normal course of events in business.” He said his greatest concern is the rise in uncompensated care as the insurance markets continue to teeter on the verge of collapse.
“The more concerning piece is whether or not the coverage that is going to be available is going to be affordable for members that are losing plans,” he said. “Will they be able to pick up and afford the Cigna coverage?”
If they can’t, all three hospital systems across the region will almost certainly see an increase in uncovered and uncompensated care, and more people in the Richmond area will find themselves shouldering medical debt.
As premiums skyrocket, plenty of people in Richmond are considering dropping their individual market plans, crossing their fingers and hoping their good health protects them from unexpected medical bills. It’s an especially appealing choice to those who are approaching age 65, when they will qualify for Medicare.
Among those individuals is Byrd, a 61-year-old Richmond resident.
Byrd is retired and has a fixed income. As rates steadily rise, she sees before her a time when she simply will not be able to afford the premiums. Now she pays $550 a month, with a $7,000 deductible.
“If it goes up to $800 a month, which is what it looks like it might do ... at that point it definitely doesn’t make any sense to buy, I’ll just wait until I turn 65,” she said.
Byrd considers herself very healthy and has no chronic health problems to concern her. Still, going without insurance makes her uneasy.
What if something were to happen?
“Actually, I’m trying not to think about it, but of course it’s scary,” she said. “But I feel like they have you by the jugular, and they keep squeezing and squeezing and squeezing, and at some point, I feel like I have to say enough is enough.”
Many people in the Richmond area see only headlines that the average premium increase across the individual market is almost 60 percent. They don’t know yet how that will impact them individually until healthcare.gov is updated closer to the start of open enrollment on Nov. 1.
Cigna’s filings to Virginia’s Bureau of Insurance say the minimum increase for a health plan will be about 24 percent, while the maximum is 168.6 percent. For a payment like Byrd is making, that would mean an extra $132 to $927 dollars a month.
Chris Lynch, a local insurance broker specializing in health insurance, pointed out that Cigna’s plan could be a good option for some people. An HMO can be affordable for some and allow members to access their desired care.
The trouble starts when it becomes the only option available, and when the premiums rise so drastically.
People who want specialized care at VCU Health, Richmond’s only academic medical center, won’t be able to if they buy a plan on the individual market next year.
“There are some services that are pretty unique to VCU Health, and we think about the patients that we’ve served who have chronic conditions and serious illnesses, and we worry about how they will find care,” said Sheryl Garland, vice president of health policy and community relations at VCU. “We are very concerned about patients who may need very specialized care, having their services disrupted and their relationship with their providers interrupted.”
As an academic medical center, VCU Health offers care of some rare cancers and pediatric diseases, among other disorders, that community hospitals frequently do not.
Both VCU and Bon Secours, though, expressed a hope of being able to come up with some sort of plan that will help patients who face a changing provider network next year.
“Our biggest concern is, if we are not in the network, then how can we ensure that patients, many of whom have received services from us in the past, maintain access to those services, which may mean having some out of the box, innovative conversations with HCA,” Garland said.
HCA and VCU Health have partnered in the past to offer care, such as when VCU providers worked in the neonatal intensive care units at HCA’s Chippenham and Johnston-Willis hospitals. The work allowed patients who want to give birth at one of the community hospitals access to care with an academic focus.
It is unclear if more partnerships could be created next year.
In a prepared statement, Tim McManus — president of the HCA Capital Division and senior executive with HCA Virginia — said HCA has been “working in partnership with Cigna’s clinical and business leaders in advance of the upcoming enrollment period,” and that the system “stands ready to coordinate” with other providers to ensure a smooth transition of care.
Herbert expressed the same concerns for Bon Secours patients. He said some prefer to receive care from a faith-based organization, and now that choice is being taken away from them.
He said the health system hopes to work with Cigna to transition care for patients who will no longer have Bon Secours as an in-network provider.
“I think common sense will prevail here, that we will formulate some kind of arrangement,” he said. “For example, one idea would be that patients that are in the facility on the 31st of December are not going to be expected to transfer the following morning to another facility. We would have an arrangement that would work with Cigna to have some kind of ongoing treatment.”
In its statement, Cigna indicated that it does intend to work not just with HCA but also “other local providers to provide support for customers who will be moving to Cigna coverage on January 1st.”
But even if both health systems are able to develop arrangements for continuity of care, thousands of people in the Richmond area will have a great deal of choice taken away from them.
Few people understand the gravity of that like Kate Vehrs, a 22-year-old Henrico County resident. She deals with anxiety and depression, and knows that it takes time to build up strong relationships with mental health providers that can lead to meaningful treatment. This year, she bought Anthem coverage on the individual market. Next year, when Cigna is the only insurer in town, she worries about having to start searching for a new doctor.
“It’s terrifying,” she said. “Some doctors I’ve been to, they don’t know what all I’ve been through, they don’t know how far I’ve come and what I still need.”
Some of the rhetoric promoting the ACA’s marketplaces from the federal government and advocates, from the beginning, was that it would improve choice and affordability for millions of Americans. But in Virginia, and a large swath of the rest of the country, choice has been all but eradicated.
“This year, it looks like many counties throughout the whole state are going to have only one insurance company to choose, and that’s really making people very nervous,” Lynch said. “It just feels like they’re getting hung out to dry.”
Lynch has been working as a health insurance broker since 2010, so he’s seen it before and after the ACA. He said that when the marketplace was started, people were nervous but they at least had options that allowed them to find what they needed.
This year, Lynch and his clients know that is not the case, but they won’t know for sure what their options are until about a week before Nov. 1, when open enrollment begins.
The individual market’s problems of too few insurers and high premiums have persisted for years, since it was enacted during President Barack Obama’s administration. From the beginning, the market faced the major problem that not enough healthy people were signing up to balance out the cost of sick people.
But this year, the issues with the market are only growing more stark due to action — or inaction, in some cases — from the federal government.
President Donald Trump — who has openly stated that his administration will “let Obamacare fail” — has refused to promise to pay insurance companies cost-sharing reduction payments. Insurers are required to offer those reductions to low-income members buying on the exchange. But with no guarantee that they will be compensated, offering plans on the marketplace has become far less attractive.
The Centers for Medicare & Medicaid Services has done little to make it easy for people to sign up for plans. It announced earlier this year that the enrollment period will be half as long as it usually is, lasting from Nov. 1 to Dec. 15.
“If we’re lucky, we get notification on finalization of what the plans are going to be, maybe a week before Nov. 1,” Lynch said. “So you’re under the gun from Nov. 1, I’ve got a very short time frame to figure this out, and I have basically no advance warning of what things are going to look like for 2018.”
And to further complicate the situation, CMS recently said the marketplace website, healthcare.gov, will be shut down every Sunday of the open enrollment period except Dec. 10 for maintenance. It will also be shut down overnight on the first day of open enrollment.
Making it more difficult for people to sign up for a plan will only enhance the individual market’s problems, Lynch said.
“What you’re going to see is continuation of the death spiral,” he said. “There’s not going to be the push out there to get all the healthy people in the plans, to help offset some of these costs for the sicker people. Without the push, without the advertising, without the notification, people won’t be aware they need to get health insurance, and only the people that really are driving the cost up, the people with chronic conditions, will sign up.
“It’s just going to further the acceleration of the collapse.”
Lynch buys his family health insurance plan on the individual market. He expects his premiums will be $817 a month next year, with a deductible of $6,400. That deductible is per person, up to a maximum of double for the family, he explained, which basically makes it a $12,800 deductible.
That means he has a lot of money he has to spend before his family could benefit from coverage should something catastrophic happen.
But the other option — to go without insurance — wouldn’t make sense for him, either.
“It’s there for me just because, if something happens to somebody in my family, and you go into a hospital and sneeze, basically, it’s 50 grand, easily,” he said. “That’s a bill that would just destroy the work that I’ve been doing trying to build a financial future for my family. So you can’t take that risk. But it’s a painful pill to swallow.”