With the penalty for dropping health insurance or a noncompliant Affordable Care Act policy set at $0, alternatives are expanding and, in some ways, Durango is ahead of the curve.
Direct primary care is a nontraditional practice that is relatively uncommon, but there are at least two direct primary care practices thriving in Durango.
Two Durango doctors who offer direct primary care – Dr. Kristen Searfus of Mountain View Family HealthCare and Dr. Don Schaefer of Whole Health Family Medicine Clinic – say most of their clients are insured either through private insurance or Medicare.
But they also see an increasing possibility of people whose incomes are too high to qualify for subsidies for an ACA plan through Connect for Health Colorado to combine use of a direct primary care physician with a catastrophic plan or another, cheaper ACA-noncompliant plan to provide their health coverage.
“I think with the elimination of the ACA penalty, I will be seeing more people with noncompliant plans,” Searfus said. “I would encourage people in their 50s and 60s who make too much for Medicaid and are too young for Medicare to sign up for direct primary care because they will actually be able to see a doctor.”
Reducing the fine to $0, Schaefer said, will lead to “a cascade of events” that in the end likely means group insurance rates will become more expensive because younger, healthier workers will be free to shop for less expensive plans that provide less coverage or to drop coverage altogether.
Schaefer sees group health insurance plans likely to increase an additional 15 to 20 percent with the zeroing out of the ACA penalty.
Searfus concurs that traditional health plans that are ACA-compliant are likely to get more expensive.
“What if only people with bad driving records had auto insurance?” she said.
One benefit of the new environment providing more alternative types of insurance may be more physicians adopting the direct primary care model, which eschews insurance for monthly fees paid directly to a primary care physician, who can handle 80 percent of routine medical needs.
“The reason I like direct primary care practice is I don’t deal with insurance billing. It facilitates things for the doctor and the patient. It gives you an ability to spend more time, useful time, with patients,” Searfus said.
With lowered cost structures to operate, Searfus said direct primary care physicians usually maintain about half the patient load as physicians tied to insurance policies. The smaller caseloads, she said, allows for longer visits with the doctor and the ease of getting an appointment with a primary-care physician.
Direct primary care simplifies the office structure because the doctor doesn’t have to hire office workers to deal with insurance, she said. Also, she said insurance reimburses poorly for procedures.
“With insurance, you need to run more people through the system in order to cover costs, lights, utilities, staff. It obligates the system to feel like it does. When you take insurance out of the equation, you can see a smaller amount of people and spend more time with them,” she said.
“With direct primary care, you have access to a doctor you know. He knows your hobbies, he knows your lifestyle, He knows your family, your kids,” Schaefer said. “You have a confident relationship with your doctor, and you have access today or tomorrow. When confidence builds between a doctor and a patient and you can dig into preventing problems and that’s where you can lower health costs.”
Both Searfus and Schaefer charge patients a monthly fee – for Searfus, $70 per adult, and for Schaefer, $58 to $99 depending on age – with no other fees for doctor visits. Both say the model creates closer relationships with patients and creates more availability to see your physician.
“I don’t have high volume. If you ask for an appointment, chances are I can see you that day or the next day,” Searfus said. “Direct primary care is more satisfying as a doctor. You really understand what is going on with your patients.”
Both Searfus and Schafer say most of their patients also have insurance, either through their employer or Medicare or Medicaid, and they encourage insurance coverage to handle catastrophic conditions and accidents that will require hospitalization and the services of a specialist.
“I encourage insurance because if something happens, I don’t want patients to be medically bankrupt,” Searfus said.
Despite the difficulty finding affordable health insurance, Schaefer said people do their best in a difficult environment.
“My biggest take away: In 18 years of practice – people are smart and resourceful. They will find ways to meet their needs even if the options aren’t particularly appealing.”
Cheaper policies that offer limited coverage are expected to proliferate with the penalty for not holding health insurance now set at $0. But costs for ACA-compliant policies offered to employees through their employers are likely to rise.
For people who are young and healthy, the changes could open more affordable health insurance options. For older workers and those with pre-existing conditions, who typically are denied coverage on alternative plans, the likely consequence will be increasing health insurance costs.
Ken Bates, owner of
Durango Insurance Professionals
, said he expects younger, healthier people in the workforce to migrate away from more expensive
plans as they gain access to cheaper, but less-generous noncompliant ACA-policies.
In addition, with the penalty for not holding ACA-compliant policies set at $0, dropping health insurance altogether becomes more attractive to the young and the healthy, he said.
“I think you are going to see more people going to alternative plans or choosing to go without,” he said.
Those making that decision, he said, are likely to be young and healthy workers, who can meet requirements of slimmed down alternative health plans, which typically do not accept people with pre-existing conditions.
“Typically, young and healthy people are who insurance companies want to offset older, less healthy people in the pool,” Bates said.
The likely result, he said, will be employers who are forced to increase deductibles and the employees’ share of monthly health insurance premiums to keep up with increasing costs of having an older and less healthy pool of people.
At least for the enrollment period for 2019, elimination of the penalty for not having ACA-compliant health insurance didn’t dissuade Coloradans from signing up for individual plans through the state health exchange,
Connect for Health Colorado
According to Connect for Health Colorado statistics, 169,672 residents signed up for individual ACA plans on the health exchange for 2019, a 2 percent increase compared with the 165,777 residents who signed up in 2018. In La Plata County, 3,123 people signed up for plans with Connect for Health Colorado in 2019, almost a 7 percent increase from 2018.
The increase comes despite increased costs for ACA plans through the exchange. A study conducted by the
Kaiser Family Foundation
reports the cost of the monthly premium for the lowest-cost silver plan through Connect for Health Colorado for a single 40-year-old in La Plata County increased from $132 in 2018 to $185 in 2019, a 39 percent increase.
Joe Hanel, communications director with the
Colorado Health Institute
, a nonpartisan, independent think tank with a mission to provide independent data analysis and research to decision-makers about health policy, said it is hard to get data about the number of people who are dropping their health insurance offered through their employer.
The attraction of an employer paying half to two-thirds of monthly health insurance premiums is a powerful motivator to not drop health coverage at work, Hanel said.
However, if rates continue to rise, he said, a combination of pairing a low-cost catastrophic policy with an affordable direct-primary care policy to care for routine needs will likely grow more popular.
One limitation, Hanel said, is the dearth of physicians offering direct primary care, which provides primary care for adults based on a monthly fee generally ranging from $50 to $100, with additional smaller fees to add children.
A study in June 2018 by Colorado Health Institute showed only 63,000 patients, about 1 percent of the state, were covered by a direct primary care physician, Hanel said.
Merida Odiorne with
, said alternative plans will become increasingly popular with people who earn too much money to be eligible for an ACA-subsidized plan.
The plans, which offer less coverage than ACA plans, will be cheaper, but they often disqualify people with pre-existing conditions.
For most people, she said, it still makes sense to check with Connect for Health Colorado for plans, because most people will find they are eligible for subsidies offered through ACA.
She noted a family of four can earn up to $100,400 and still be eligible for a subsidy for an ACA plan.
This story has been update to list Merida Odiorne’s correct affiliation with USHealth Advisors and to note US Health Advisors does not sell short-term plans.