Affordability

The unaffordability of healthcare remains a sore subject for most Americans. There is no single factor that can be pointed to and dealt with to make healthcare affordable. For most Americans access to care is directly related having some form of “health insurance” coverage (Medicare, Medicaid, Veterans Administration, Employer sponsored, Individual plan via a commercial health insurer). However, having some form of health insurance coverage does not guarantee adequate or affordable care. The health plan may or may not cover care for all conditions, may or may not include the best-in-class providers for covered conditions, may or may not cover the full cost of care.

For individuals seeking quality affordable care, shopping for care is a required activity. It is even more critical to know what to shop for, hence knowing what questions to ask when seeking care is key.

Some resources when seeking affordable quality care (Access to the internet has become a fundamental requirement)

1. Insurer’s website or app: If one is covered by a health insurance plan, they should check out the insurer’s websites and the insurer’s “apps” for information about care providers in the insurer’s network and contact the insurer to find out more about the doctors, the conditions and the cost of the procedures.
2. If one has a Primary Care Physician (PCP), they should inquire with the PCP about the condition, the required care in order to treat the condition or prevent complications, and remedies, if there are multiple choices for care and remedies ask why one should be preferred over another specifically for the individual seeking care
3. For the un-insured or under insured, the search and access to affordable quality care is rather challenging, below are some starting points

• • In the United States, each State governs the healthcare needs of its residents in partnership with the federal agencies. Currently, there are three state-based health coverage programs:

• • • Medicaid, which provides health coverage to low-income people and is one of the largest payers for health care in the United States. Under federal law, the states are required to provide certain mandatory benefits and other optional benefits if they choose. The list of mandatory and optional benefits can be found here
    • The Children’s Health Insurance Program (CHIP) provides federal matching funds to states to provide health coverage to children in families with incomes too high to qualify for Medicaid, but who can’t afford private coverage.
      For the un-insured or under insured, the search and access to affordable quality care is rather challenging, below are some starting points
    • The Basic Health Program (BHP) allows states an option to provide affordable coverage and better continuity of care for people whose income fluctuates above and below Medicaid and CHIP eligibility levels.

The most recent (as of 2020) full list of managed care covered benefits for each state can be found here

Note: Despite the availability of this information on the agency websites, it is not easy for an average uninsured (or underinsured) to determine whether a condition will be covered by the state healthcare programs.

• • There are organizations such as Patient Advocate Foundation that provide services to eliminate obstacles in access to quality healthcare. Two useful links on their website are

• • • Resources to help finding care when uninsured
    • Directory of available financial resources (charities, grants and other programs) they help fund care

Sustained affordable care will require whole sale changes in the dynamics of the industry value chain, some of which should include the following

1. Meaningfully increase in the supply (competition) of high quality safe care with a combination of human and technology based care that may be sourced globally
2. Elimination of redundant administrative burden across the healthcare value chain
3. Adequately funding the safety net programs that deliver equitable access to healthcare for all population segments and hold the principals of the programs accountable for their success
4. Inspire behaviors that encourage accountability for good health by the individuals themselves and the care givers

The complexity of such changes is beyond the scope of a single individual or a single organization to effectuate.

Lack of transparency and Surprise Billing: