Are health insurance costs rising beyond Virginians’ ability to pay their bills?

• Healthcare costs and insurance premiums continue to rise. The annual amount employers and workers pay for health insurance has risen at a rate higher than the increase in wages or inflation, and high-deductible insurance plans that require families to pay greater out-of-pocket costs have become increasingly prevalent. In short, people are paying more and getting less comprehensive benefits.
• In 2018, the estimated annual healthcare costs for a family of four was $28,386.
• Data from the State Corporation Commission’s Bureau of Insurance shows that from 2014-2020, average health insurance premium costs rose 130 percent.
• In addition to premiums, the out-of-pocket deductibles families pay for care continue to grow.
• In 2003, average Virginia insurance deductibles were $500; by 2013 average deductibles rose to $1,173.
• The U.S. Centers for Disease Control and Prevention reports that more than 40 percent of Americans are enrolled in high-deductible insurance plans.
• And according to the Kaiser Family Foundation, the average insurance deductible for a single U.S. worker is $1,655, double the amount it was 10 years ago.
• Meanwhile, there has been a sharp decrease in competition within the health insurance marketplace, meaning fewer larger insurers wield greater influence over healthcare coverage and cost decisions.
• American Medical Association research indicates that in nearly all of the U.S. metropolitan statistical areas (91 percent) at least one insurer holds a 30 percent commercial market share, and in about half of MSAs (48 percent) one insurer holds a market share of 50 percent or more.
• In Virginia, one health insurer controls 40 percent of the market share.

How does the insurance industry impact your ability to access affordable healthcare?

• Big insurance companies have significant influence over how families access healthcare services and what they pay for treatment. That influence is expanding as companies merge and increase their market share, which limits patient choice.
• Insurance companies essentially operate on a cost-control model. That means the less an insurance company pays out for claims and benefits, the more profit it makes.
• One way big insurance companies limit their costs is through something known as “prior authorization,” which means an insurance company must first approve a treatment ordered by a doctor before the patient may receive it. This cumbersome process interferes with the doctor-patient relationship and research has shown it can lead to less effective treatment for patients and increase costs for physicians.
• Some insurance companies like Anthem, Virginia’s largest insurer, have begun restricting where patients may receive MRIs, CTs, and other medical scans in a move that is focused on profit margins rather that patient needs.
• Insurers also define how broad or narrow coverage networks are, impacting which health care providers patients can see for care depending on whether the insurer classifies providers as in-network or out-of-network.
• Sometimes in emergency medical situations, a patient who unknowingly receives treatment from an out-of-network healthcare provider later receives an unexpected medical bill because the insurer didn’t pay a reasonable share of the costs.
• This is known as surprise or “balance billing.” In 2019, healthcare providers, patient, and consumer advocates supported bipartisan legislation to protect patients from balance billing in emergency medical situations by establishing a fair market payment rate when these situations occur and preventing insurance companies from denying a patient’s emergency care claim after the fact. Despite passing the Virginia Senate unanimously, the bill was not passed into law as a result of insurance industry objections.
• Insurance companies can limit patients’ access to necessary medications if they determine certain drugs are too expensive. Insurers have taken those profit-minded steps as prescription drug costs have risen. Prescription spending at pharmacies accounted for 9 percent of the total $3.6 trillion national health care tab in 2018.

How easy will it be to get an appointment with a doctor in the future?

• Virginia is experiencing a shortage of medical professionals that will only get worse in coming years. Virginia’s healthcare workforce is aging, and the number of training opportunities is not keeping pace with Virginia’s population growth. This means Virginians struggle to access medical care, especially specialty care, in a timely manner.
• In 2016, Virginia had 262.4 active doctors per 100,000 people – which puts Virginia directly in the middle of all states nationally.
• 29.3 percent of Virginia’s physicians are over the age of 60.
• As doctors in Virginia get older, the workforce issue will continue to grow. Currently, the state trains only 26 new doctors per 100,000 people per year – while the national average is 36 per 100,000.
• Virginia ranks #18 in access to healthcare; as doctors get older and with fewer doctors to replace them, it will be harder to see the doctor.