WHY This COALITION IS NECESSARY
Most people in the United States have some kind of health insurance coverage. Yet for millions, that coverage all too often doesn’t translate into treatment or care. In fact, more than a third of Americans with health insurance do not get the care their doctors say they need because they can’t meet their health plan out-of-pocket requirement.
Many Americans now have no choice but to enroll in a plan with high out-of-pocket requirements, regardless of where they get their coverage. Insurers and many employers have gradually eliminated other options that were once available. They have promoted high-deductible plans as a means of keeping premiums from rising even more rapidly than they have, but when out-of-pocket requirements are factored in, the total cost of coverage becomes unaffordable, especially for people with chronic conditions. High-deductible plans all too often provide only the illusion of affordability.
Over the past decade, out-of-pockets have increased so much that more than 40% of people who buy coverage on their own--and nearly 30% of individuals and families who have employer-sponsored health insurance--are now underinsured. That means that millions of Americans with insurance can’t afford to pick up their prescriptions or see a doctor when they get sick. (Being underinsured is defined as someone whose out-of-pocket costs equal 10% or more of their income, or their deductibles equal 5% or more of their income.)
As Congress and the White House assess policies to make healthcare more affordable and equitable, it is imperative that it consider more than expanded insurance coverage and premium subsidies. Those proposals have merit but do not provide the financial relief middle-class Americans really need and expect from policymakers. Any reforms must address out-of-pocket costs.
High-out-of-pockets keep patients from getting necessary screenings, treatments, and medications. Health insurers claim that co-pays keep patients from seeking unnecessary services, but the reality is much different. Health plans can be designed to guard against overuse or inappropriate use while also making health care affordable at the point of service.
This project is years in the making.
The Lower Out-of-Pockets NOW coalition is being led and staffed by former health insurance executive Wendell Potter and his team at the Center for Health and Democracy. Wendell headed corporate communications for Humana and Cigna before leaving the industry to become a health care reform advocate and leading critic of health plans that leave millions of Americans inadequately insured.
As Wendell testified before Congress during the debate on what became the Affordable Care Act, one of the reasons he walked away from his career was his opposition to what had become an industry-wide strategy to shift as many Americans as possible--and as quickly as possible--into high-deductible plans. He anticipated exactly what has happened since then: millions of Americans falling deeply into debt or forgoing needed care because of their inability to meet their out-of-pocket requirements.
Wendell has written and spoken extensively for more than a decade about the cost crisis facing working families. The idea for a coalition to address this growing crisis grew out of conversations he has had over the years with people representing a broad range of organizations and businesses and with policymakers and other health policy experts.
In mid-2021, Wendell and many of the people he spoke with, including Jim Greenwood, a former Republican Congressman from Pennsylvania and retired leader of the Biotechnology Innovation Organization, resolved to start an organization that would bring national attention to the problem of skyrocketing out-of-pocket costs and to advocate for solutions.
President, Center for Health and Democracy and Business Leaders for Health Care Transformation