A man struggling with alcoholism died after trying unsuccessfully for months to find a mental health therapist covered by his Obamacare plan.
An NPR/ProPublica report describes in depth the events preceding Ravi Coutinho’s May 2023 death, apparently from an accident involving a relapse into alcohol abuse while alone in his Phoenix apartment.
Coutinho’s Ambetter plan, purchased for $379 a month from the HealthInsurance.gov federal marketplace, appeared at first glance to have plenty of providers in the Phoenix area, but every lead Coutinho followed went cold.
Coutinho’s search for a therapist was a key part of his treatment plan, as recommended by his previous therapist from his time living in Austin, Texas.
Even the help of his friends and family—his mother worked as the head of a New Mexico health care access advocacy group and had a connection who worked for Ambetter parent company Centene—could not get him the care he needed, according to the report.
Tragically Perverse Incentives
The tragic tale laid out in the NPR/ProPublica report mirrors a problem with the Affordable Care Act identified by John C. Goodman, president of the Goodman Institute for Public Policy Research and co-publisher of Health Care News, a decade ago in a 2015 Forbes article.
“Health plans are keeping premiums down by choosing narrow networks that leave out many mental health providers,” wrote Goodman. The “networks themselves are frequently deceptive,” Goodman wrote, citing a report that just 14 percent of psychiatrists listed in qualified health plans in the Maryland marketplace were available and taking new patients within 45 days.
Goodman calls the problem a “race to the bottom” caused by government rules giving insurers distorted incentives to provide worse coverage.
“In the [Obamacare] exchanges, health plans get the same premium regardless of the health status of the person who joins the plan,” Goodman told Health Care News. “That gives them an incentive to attract the healthy and avoid the sick.
“Patients who do not have mental health problems are more profitable than patients who do,” said Goodman “This is true for all chronic conditions, but it is especially true for mental health.”
Massive Moral Hazard
Twila Brase, founder and president of the Citizens’ Council for Health Freedom and registered public health nurse says there is another reason why Obamacare is problematic.
“Obamacare opened wide the door to subsidized coverage and coverage for people with preexisting conditions,” said Brase. “It introduced massive moral hazard because taxpayers are paying the bill.”
Every health plan, Brase said, “rations care through prior authorization, network limitations, hiring fewer practitioners than needed, long waits for appointments, drug formulary lists, and corporate treatment protocols which directly control medical decision-making.”
Advantages of Traditional Plans
Tragedies like Coutinho’s are far less likely under traditional indemnity-based insurance plans that keep costs down by covering only large health care expenses and have more freedom to accept or reject people with preexisting conditions or at least price them more in line with the cost-risk they present, says Brase.
“In a world of indemnity insurance, prices would be known, prices would be competitive, and charity would be more available because doctors would set their prices according to what most people would be willing to pay, and the doctor could afford.”
In addition, “Indemnity insurance does not have networks” that limit the range of providers, said Brase.
Fewer people might take up appointment slots, reducing wait lines for all patients, says Brase. There is also the prospect of out-of-pocket payment. Therapists can be found for less than $150 an hour, but “whether that therapist is near you is another question,” said Brase.
Telehealth and charity or church ministries are other ways to lower costs and make it easier to get mental health treatment.
Unnecessary Expenses
Obamacare expanded Medicaid to cover more people which is another reason why it has become harder to find a therapist.
“Today, Medicaid consumes the time of practitioners unnecessarily through boatloads of paperwork,” said Brase. “They’d have more time and energy if all payments were direct, not third-party funded. That also means prices could be lowered since they wouldn’t have to do all the requisite government and health plan paperwork.”
Insurance Addiction
Third-party payers’ domination of health care is behind most of the flaws in the system, says Brase.
“The biggest problem is networks, third-party controls, bureaucracy, and the fact that the American mind is not used to thinking of health care as a cash-based item,” said Brase. “That needs to change, or care and coverage will remain unaffordable and less accessible, and every patient and enrollee will continue to be exploited for the profit it provides the health plans and the political agendas driven by government subsidy programs.”
Insurance is not designed for everyday primary care, Brase says.
“Primary care is not an insurable event,” said Brase. “Insurance should only be to insure you against a financial disaster—in this case, unaffordable, high-cost medical expenses related to catastrophic or insurable events, like coma, car crash, cancer, and expensive chronic conditions.
“And there should always be skin in the game until costs reach the level of reinsurance,” where the insurance company has purchased its own insurance to cover the most expensive situations, said Brase.
The way we think about insurance under the Obamacare regime inevitably leads to these problems, says Brase.
“Insurance is not for primary care, but since it’s being used for that, it’s more expensive and less accessible to patients,” said Brase.
Harry Painter (harry@harrypainter.com) writes from Oklahoma.
