Obamacare went a long way toward preventing the insurmountable medical bills that led to a large percentage of U.S. bankruptcies. But for many people, the $6,600 per-person, per-year cap on out-of-pocket costs might as well be $600,000, it’s so unlikely they could pay it.
This is a problem many people will never have to worry about. Without a major disease or accident requiring costly specialty drugs or surgery, very few of us will have enough co-payments and cost sharing to total $6,600 in any year, much less every year. Even fewer families will have so many medical bills that their share will reach $13,200, which is the family maximum for plans purchased on Obamacare exchanges.
“It’s like a hole that has to be filled,” says Jose Fernandez, associate professor of economics at the University of Louisville. “The whole idea behind it is to make insurance act like insurance rather than a YMCA membership.” Traditionally, health insurance paid for all sorts of routine care, and the patient just had to chip in with a co-pay, he says. These days, however, patients are being asked to pick up a much bigger chunk of the tab. That happens first through deductibles, which are what you pay before insurance chips in. Out-of-pocket maximums include deductibles as well as co-pays and co-insurance, but not premiums or cost-sharing when you get care out of network. Maximums for private plans are often lower than $6,600 — sometimes by a lot — they just can’t be higher.
Christian and Jaycee Garcia of Silver Spring, Md., have been hard hit by medical bills, even with their out-of-pocket maximum of $6,350 a year for each family member. Their 20-month-old son, CJ, was born with the rare genetic disorder Eagle Barrett Syndrome and severe scoliosis. He will have his 13th surgery in August, with two more to follow in September, all to rebuild his digestive system and urinary tract and to insert metal rods next to his spine so he can sit up without a brace.
