AAA Approach to Plugging PPACA Access Gaps

A Pennsylvania company is offering a healthcare coverage option to segments of the population still struggling with access to affordable healthcare: the middle class and undocumented aliens.

The limits of the federally driven effort to boost access to affordable healthcare are coming into focus as the political limits of the Patient Protection and Affordable Care Act's healthcare accessibility potential are being tested on two fronts.

In a dozen Republican-leaning states, political opposition is blocking several million adults from gaining health coverage through Medicaid expansion under PPACA guidelines.

And in Washington, political gridlock has blocked immigration reform legislation, making the ED the site of first resort for more many of the country's estimated 11.5 million undocumented aliens seeking healthcare.

The economic limits of the PPACA's push for affordable healthcare are being tested in the middle class.

"The working middle class is truly being priced out of healthcare," Betty Heiman, MBA, co-founder and CEO of Swarthmore, PA-based Transparent Health Group LLC, told me recently. When accounting for undocumented aliens, who are not eligible for healthcare coverage under the PPACA, she estimates the number of uninsured and underinsured people after full implementation of the law could be as high as 40 million.

Heiman defines the working middle class as households with annual incomes ranging from $60,000 to $125,000. The PPACA-spawned public health insurance exchanges are not an affordable option for millions of Americans in this income bracket, she says, because most comprehensive plans in the "platinum" category have high monthly premium rates and HIX health plans with low premiums have high out-of-pocket costs.

"Affordability is a challenge for the middle class. In many cases, people are looking at a very significant deductible," she says.

I get it.

My family is fortunate enough to be in this income bracket. We are also fortunate enough to have a relatively generous health plan through my wife's employer. However, if I got kicked off my wife's health plan and had to buy health insurance through the federally administered exchange in New Hampshire, the numbers are sobering from my working middle class perspective.

After plugging some basic information into the user friendly cost estimator on HealthCare.gov, I perused the 16 available "silver" category health plans, a middle-of-the-financial-road option for most consumers.

Boston-based Minuteman Health Inc. offered healthcare coverage at the lowest monthly premium, $347, with a $2,000 deductible and maximum annual out-of-pocket expenses pegged at $6,000. Milwaukee, WI-based Assurant Health offered coverage at the highest monthly premium, $705, with a $2,000 and maximum annual out-of-pocket expenses pegged at $6,350.

Assurant also offered the lowest cost health plan comparable to our family's plan, "gold" category coverage at an $849 monthly premium, with no deductible and maximum out-of-pocket expenses pegged at $6,350.

My family budget might survive the financial hit of Minuteman's lowest priced silver plan. The Assurant gold plan is surely out of reach and comparable to personal finance calamities on the scale of replacing the entire roof of my 110-year-old house.

'This is Not Insurance'
Heiman's organization has created Transparent Healthcare, which is taking an unconventional approach to boosting access to affordable healthcare coverage to the middle class and undocumented aliens. "This is not insurance," she says.

Launched in 2009, it could become the AAA of healthcare, a membership-fee-financed organization that features access to a range of services and discounted pricing.

"If you're paying for healthcare on your own, you're paying too much," Heiman says. "You can't contract or negotiate the way the big players do." And adding the billing rates for the uninsured at most hospitals is about five-fold above Medicare billing rates.

Focusing on predominantly urban counties, Transparent Healthcare has established a network of participating providers in three states: New York, New Jersey and Georgia. For $39 a month, every member of a family household gets access to a wide range of medical services at Medicare-comparable rates and 24/7 telemedicine access to a doctor.

"Our members understand the cost of care before they go through the door," Heiman told me. "They're walking in with a sense of dignity. They don't have to announce that they are uninsured, or have no idea of the cost of care."

Telemedicine Component is Key
She says unlimited free access to telemedicine is a prime component of Transparent Healthcare's approach to boosting healthcare accessibility for the previously uninsured, the underinsured, and the undocumented.

"That sets us apart. It avoids deductibles and copays. Telemedicine is part of the subscription rate. There is absolutely no cost out-of-pocket. Physicians can prescribe over the phone for many conditions. This provides a significant opportunity to speak to a doctor."

Transparent Healthcare members pay cash on a pay-as-you-go basis, which is a draw for providers, she says. "Billing can account for as much as 15% or 17% of a doctor's expenses. When they work with us, they're not billing. They're not waiting 30, 60 or 90 days for payment."

Jessica Hicks, President of Nyack, NY-based Grandview Physicians Billing Service, says Transparent Healthcare is a win-win for providers: increasing patient volume and lowering costs.

"Transparent Healthcare increases our reach into the community by bringing a new set of patients into our offices. Working directly with Transparent we save on billing and collection costs, as the patient pays directly at the time of service. Their customer service makes the process so simple. I wish all networks were this easy."

Placing a Premium on Patient Experience
"The time has come in healthcare to increase the level of customer service. We offer concierge services, helping patients find a doctor and prescription drugs at affordable prices," Heiman says. Transparent Healthcare is offers price comparisons for selecting doctors and pharmacies and allows "for the very first time, what the healthcare consumer needs – ease of use and transparency about price."

Heiman says the PPACA alone is destined for failure in its quest for universal healthcare coverage, which has opened a niche for entrepreneurialism and innovation. "Without these access gaps, there would be no room for us. The fact that there is a market of 30 to 40 million people creates a market opportunity.