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Health Reform 101

with Lisa Zamosky

WebMD helps readers understand their health insurance and the new health care reform law. The Affordable Care Act is bringing sweeping changes to American health care. Lisa Zamosky is here to help you navigate the health care maze and understand how these changes affect you.


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Friday, December 13, 2013

The High Cost of Medical Care

By Lisa Zamosky


As the implementation of the Affordable Care Act marches on and more people sign up for insurance, the details of those plans and how much people pay toward necessary care is getting greater attention.

One WebMD reader wrote to me recently with the following observation about the plans available to her through her state’s health insurance Marketplace:

With the subsidies, my cost of health care premiums should be below $200.00 a month, yet with $6000 in deductibles… does not sound like I can afford to go to the doctors even if I need to.

Hers is just one of many similar observations I’ve heard from consumers shopping their insurance options, and the beginnings of more people recognizing that the premium, or the monthly payment you make to have a health insurance plan, is just one aspect of your total insurance costs.

Out-of-Pocket Costs with Exchange Plans

The Robert Wood Johnson Foundation in partnership with healthcare consulting firm, Breakaway Policy Strategies*, conducted an analysis of out-of-pocket costs associated with silver-level plans being sold in 15 different state Marketplaces around the country. The analysis looked at the average price of deductibles, co-pays and co-insurance.

It highlights a few eye-opening averages:

  • Deductibles, or the amount you pay before insurance begins to help cover your costs, averaged just less than $2,800 per year.

That’s actually a slight improvement over the average consumers with private health insurance coverage pay today. According to online insurance broker,, the average deductible for a private health insurance plan is currently $3,079.

  • Co-payments for in-network visits to a primary care doctor (PCP) averaged $30 per visit for Obamacare plans.

Compare that with today’s private plans which require an average co-pay of $28, according to an analysis of private plans by, a website that ranks and compares health plans.

  • Co-insurance, the percentage of a visit’s cost you must pay, averaged 15% for PCP in-network visits in new plans, according to the RWJF analysis.

The nationwide average for co-insurance charges for today’s plans, by comparison, is 20%.

These numbers represent national averages, and they seem to suggest that not much is changing under the new law. However, as the reader’s comment I included earlier in this post highlights, many consumers are finding their costs going up. In some cases, the increase is enough to make their insurance seem downright unaffordable.

A few things to keep in mind: Under the Affordable Care Act you won’t pay anything at the time of your visit for preventive services. And, many people will qualify for cost-sharing subsidies. If you’re an individual earning just less than $29,000 per year, the price of your deductibles, co-pays, and co-insurance will be lowered, thereby costing you less when you seek medical care.

Looking past your monthly insurance premiums to also examine the costs you pay when you actually go to the doctor is a critical part of understanding how much your insurance and your medical care is truly costing you. That means adding up your deductibles, co-pays and other out-of-pocket costs to the price of your monthly premium to determine what you’re likely to spend on health care in a given year.

To learn what your worst-case scenario would be if you were diagnosed with a serious illness or had an accident that required a lot of medical care, add up your premium and your total out-of-pocket maximum for the year to determine what your worst-case scenario could be.  And remember that under the law, plans must limit an individuals out-of-pocket costs to $6,350 and that of a family to $12,700 in 2014.

What do your costs look like? Please share your experience in the comments section below.

*The president and CEO of Breakaway Policy Strategies, Dean Rosen, also is a member of WebMD’s Affordable Care Act Expert Review Panel.

Posted by: Lisa Zamosky at 3:05 pm


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