BY SUSAN M. MATHEWS, PH.D

Who decides the definition of “affordable” for individuals and families?

Just because the ACA is named the “Affordable Care Act” doesn’t mean that health insurance is within reach for millions of Americans. A spokesman for the Department of Health and Human Services points out that the law, for the first time, caps out-of-pocket costs for families at $13,700. Can your household budget absorb that number?

There are those who argue that responsible Americans need to set priorities. Devon Herrick’s blog posits the argument that health care and insurance should trump vacations, cigarettes or the movies. However, most Americans trying to fit premiums or medical care into their budgets are not thinking about the “extras” in life. They are dealing with mundane realities of survival, and they are managing to the edge of their paychecks.

An Urban Institute study found that the median single enrollee in Obamacare earning between $35,310 and $47,080 (or a family of four earning between $72,750 and $97,000), would spend almost 15 percent of income on Obamacare premiums and out-of-pocket costs this year, even with federal government subsidies. This outlay increases to more than 21 percent if you are in worsening health, 45 and older, or between 200 and 500 percent of the federal poverty level.

Nearly 30 percent of those insured through the federal marketplace who had deductibles higher than $1,500 went without diagnostic tests, treatments, follow-up care and prescription drugs in 2014 because they could not afford it, according to the health care consumer group, Families USA.

Deductibles have grown six times faster than wages since 2010, says a recent Kaiser Foundation Study. Cost concerns have led tens of thousands of the newly insured to drop their Affordable Care Act plans and opt for free or discounted care at community health clinics.

“Unfortunately, what we are headed toward now is universal crappy health insurance,” said Dr. Budd Shenkin, a California pediatrician who wrote the American Academy of Pediatrics policy on high-deductible plans, which he calls “nefarious.”

“It’s just not a good deal for people,” Shenkin said. Last year, the Academy advised the federal government to restrict such plans to adults because they discourage families from seeking necessary primary care for children.

In response to the criticism, the Obama administration acknowledges that high deductibles are an “important issue” but maintains the problem is part of longstanding insurance trends.

‘Americans are not seeing their doctors and not depositing savings in the bank’

Meanwhile, millions of Americans have weighed the cost of forgoing coverage entirely. They pay the penalty or they bite the bullet to opt into Obamacare and essentially remain uninsured for basic medical needs.

High deductibles are particularly onerous when those not yet eligible for Medicare confront rapidly escalating end of life costs. However, the ACA does meet the need for catastrophic coverage once that deductible is met, which can mean the difference between bankruptcy or bearing the burden of payment plans to knock down hospital or doctor bills.

The ACA explicitly stepped into end of life care by promoting the need for advance directives. Less than one-third of American adults have completed an advance directive, intended to spell out the writer’s wishes about their care preferences.

While the ACA did encourage such a positive health behavior, most of the news is not positive.

In March, an analysis of medical claims from the Blue Cross Blue Shield Association concluded that insurers gained a sicker, more expensive patient population. This reality will worsen under the ACA, as more defer medical care due to high deductibles. Added to that, ABC News reports that insurers will seek significant premium increases in a wave of statewide level requests rippling across the country ahead of this summer’s political conventions.

On the sixth anniversary of Obamacare’s passage, after promises of keeping your doctor and saving an average of $2,500 on premiums, Americans are not seeing their doctors and not depositing savings in the bank. It is not surprising that last month, the overall disapproval of the law swelled to 49 percent of the public, while support decreased to 38 percent. Maybe someone inside the beltway should have asked the average citizen what the meaning of “affordable” is in the real world.

– Images courtesy Death to Stock Photos and WikiMedia Commons