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For middle-income families, Obamacare costs are a Catch-22

Xonjenese Jacobs and Ashley Richards of USF wait to help people enroll in a health care plan. The deadline is Jan. 31.
Published Jan. 18, 2016

Gary Thompson pays $550 a month for a health insurance plan that covers him and his wife.

The monthly bill strains the Tampa couple's finances. He works in cabinet design and sales. She is a hair stylist. Together, they make about $65,000.

But here's what really gets him: With the exception of a few basic services, the plan won't pay any of Thompson's claims until he has spent at least $6,500 on health care. His wife also has a $6,500 deductible.

"You spend thousands of dollars a year on insurance," Thompson said, "and you can't afford to go to the doctor."

For months, federal health officials have been touting the low premiums available to people who purchase health plans on the Affordable Care Act exchanges. They've even singled out the Tampa Bay area, where the rates for standard Obama-care plans dropped an average of 2.4 percent from 2015.

But for some middle-income earners — especially individuals whose salaries hover around $47,080, the upper limit for receiving tax credits to help offset the cost of coverage — the monthly payments are a financial burden. What's more, many have plans with high deductibles and copays that can make accessing health care virtually impossible.

"There's a group of people for whom coverage is going to be very expensive relative to what their income is," said Cynthia Cox, associate director of the program on health reform and private insurance at the non-profit Kaiser Family Foundation. "In some cases, it is so expensive that it is determined to be unaffordable."

The high costs are troubling some consumers heading into the final weeks of this year's open enrollment period. Consumers have until Jan. 31 to sign up for coverage that takes effect March 1.

Those who don't sign up — and don't have coverage through an employer or a government program such as Medicaid or Medicare — will face a steep penalty: $695 for every uninsured adult in their household or 2.5 percent of household income, whichever amount is greater.

The Affordable Care Act was signed into law in 2010 to ensure low- and middle-income earners had access to reasonably priced health insurance, regardless of their medical history.

In many ways, it accomplished that goal.

Of the 9 million Americans who purchased coverage on the Affordable Care Act exchanges in 2015, about 80 percent qualified for a tax credit to help with their premium.

The "premium tax credits" aren't the only help that's available to consumers. Individuals earning $11,770 to $29,425 (or families of four earning $24,250 to $60,625) are eligible for additional discounts on out-of-pocket costs, including deductibles and copayments.

But for middle-income consumers, premiums can cost hundreds of dollars for each member of their household. A paper published in December by the nonprofit Robert Wood Johnson Foundation reported consumers with incomes around the $47,080 cutoff spent nearly 10 percent of their annual earnings on health insurance premiums — a larger share than lower-earning consumers.

In addition to the premiums, most mid-level silver plans require some level of cost sharing from the insured.

In Hillsborough and Pinellas counties, for example, a 40-year-old man who earns $37,500 and has silver-level coverage must spend an average of $5,285 out of pocket before his insurance will help, according to an analysis of plans offered on healthcare.gov.

The average silver plan in both counties caps out-of-pocket spending for that consumer at $6,440.

"I completely understand people who feel like this is a big lift," said Katherine Hempstead, who directs research on health insurance coverage at the Robert Wood Johnson Foundation.

But Hempstead and other experts point out that most plans on the Affordable Care Act exchanges cover a set of preventative services at no cost, so long as the provider is part of the network.

They also point out that having insurance can prevent unforeseen medical bills from accumulating — and thrusting an individual or family into bankruptcy.

"It's better to have that safety net than to not have it, because there's a tremendous financial risk," said Melanie Hall, director of the nonprofit Family Healthcare Foundation.

Still, some Tampa Bay area consumers are feeling the sting of high prices.

Wally Blackburn, a 60-year-old retired medical administrator from Tampa, recently found out the cheapest coverage for himself, his wife and his 23-year-old daughter would cost $2,100 a month — a "huge chunk" of the family's monthly income, he said.

He opted to buy an $800-a-month plan for his wife, who may need back surgery later this year.

But Blackburn and his daughter are sticking with the so-called catastrophic plan they had before the Affordable Care Act. The plan, which has a $6,500 deductible and will only cover them in case of serious injury or illness, was grandfathered in under the health law.

"It can be kind of scary to think about what could happen," Blackburn said. "But the alternative is to pay an outrageous amount of money."

Gary and Maxine Thompson, who are both 62, debated going without health insurance earlier this year.

They ultimately decided they needed it.

"There's a good chance we'll encounter some sort of health care items," Gary Thompson said.

In the worst case scenario, the couple could end up spending $19,600 before their plan starts paying for their care. They've had to make some adjustments in case that happens. Rather than replace his broken car, Gary Thompson is taking Uber to jobs. He and Maxine have put off their retirement, and are also considering selling their house.

"It's just so frustrating," he said. "We're at a point where coverage really isn't affordable for us."

Contact Kathleen McGrory at kmcgrory@tampabay.com or (727) 893-8330. Follow @kmcgrory.

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