Lately, I’ve been hearing from readers who are among the million Californians who had private health care plans, received cancellation notices and now have to buy new coverage. Some figured that if they signed up with their old providers — Blue Shield or Anthem — they’d have access to the same doctors and hospitals. Not quite. In Marin, San Francisco and Alameda counties, new plans in Covered California exchanges don’t include doctors and hospitals in other counties.
Remember the initials EPO; they stand for exclusive provider organization. PPO (preferred provider organization) plans contain costs by charging lesser rates for doctors and hospitals inside their networks. EPOs, however, pay nothing outside their exclusive networks unless there is an emergency or special approval.
A Marin woman told me she believed that President Barack Obama lied when he told voters that if they liked their plan and doctors, they could keep them. But after talking to Blue Shield representatives who wrongly told her she could see her old doctors, she said: “I would put Blue Shield right up there with Obama.”
I should note that consumers in all 19 California health pricing regions have an option to buy into a PPO, but that doesn’t necessarily give them the choices they had before. A Santa Cruz breast cancer survivor tells me she thinks she can see her cancer doctors through a Blue Shield EPO, but a specialist who is treating her for treatment-related bone loss is outside the network. That means she has to pay the full doctor bill.
Again, she had to do her homework to learn the dirty details. When she looked on the Covered California website, a pop-up window described the EPO as if it were a PPO.
I remember going to an event in 2009 at which then-House Speaker Nancy Pelosi argued in favor of the Affordable Care Act because it would close gaps in coverage that left a breast cancer survivor $100,000 in debt because her bare-bones plan didn’t cover the drugs she needed.
Alas, the Obamacare cure might help Pelosi’s patient, but it leaves other women with pre-existing conditions out in the cold.
Doctors aren’t happy, either.
Dr. Richard Thorp is a Northern California internist, a primary care physician and the president of the California Medical Association. The CMA wants every Californian to have health care, yet he initially opted out of Covered California because the exchange demanded too deep a discount. Later, when exchange providers couldn’t enroll sufficient doctors in his region, they upped their reimbursement rates so that Thorp now is with the plan. But doctors who were not so lucky have to make “a difficult business decision and a difficult patient-care decision,” he said. Those doctors who can afford to see more patients for less money may have to opt for shorter visits. Blue Shield is restricting access to half its doctors.
When Obama and congressional Democrats set out to expand health care, they promised that the 85 percent of Americans who already had coverage wouldn’t get shortchanged. They lied. Now everyone can get his fair share of less care.
Email Debra J. Saunders at dsaunders@sfchronicle.com.
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