New Obamacare Loophole Shows Failure of For-Profit Health System: Critics

The Obama administration earlier this month quietly handed the insurance industry another loophole in the Affordable Care Act--infuriating advocates for universal coverage who say this shows that an insurance-driven health system is doomed to fail.

Announced on May 2, the provision opens the door to "reference pricing," which allows insurance companies to set a price for medical procedures. If a patient receives a treatment that costs more, he/she will simply have to pay out of pocket. The measure is slated to apply to a majority of work-based health insurance plans and exchanges under the Affordable Care Act (also known as "Obamacare"), according to the Associated Press.

Many worry that reference pricing will force patients to bear the burden of a costly and difficult-to-navigate medical system.

"We don't need reference pricing--we need "right pricing" under a single-payer program," Don McCanne, M.D., senior health policy fellow at Physicians for a National Health Program told Common Dreams. "This is merely another way in which insurance companies are going to chisel down payment for care, shifting a greater share of the cost onto patients."

"This new rule to limit payments for needed medical procedures is a reminder of everything that is wrong with our profit-driven healthcare system," Jean Ross, RN, co-president of National Nurses United, told Common Dreams. "Rather than crack down on price gouging by hospitals--some of who set their charges as high as 12 times their costs -- the administration is enacting a rule to ration care for patients."

Critics charge that the ruling even violates one of the Affordable Care Act's key tenets: To end "lifetime and yearly dollar limits on coverage of essential health benefits."

In its own fact sheet, the Department of Labor acknowledges concerns that "such a pricing structure may be a subterfuge for the imposition of otherwise prohibited limitations on coverage, without ensuring access to quality care and an adequate network of providers."

According to Ross, "A Commonwealth Fund study last November comparing Americans to 10 other developed countries found that U.S. adults are by far the most likely to not get the treatment their doctor recommends, as well as forgoing doctor visits or filling prescriptions, because of the high cost. All that this rule will do is increase those medical disparities and further brand our dysfunctional healthcare system as one based on ability to pay rather than on patient need."