THE BLOG
09/30/2015 02:54 pm ET Updated Sep 30, 2016

Health Insurance That Doesn't Ensure Healthcare

Blue Cross Blue Shield (BCBS) of Illinois is making life even harder for parents of kids with special needs who purchased their insurance on the Affordable Care Act exchange. And if you think it won't happen in your state, think again. Shame on our country for putting up with a healthcare system that is all about profits and doesn't give a hoot about providing either health or care.

According to Crain's Chicago Business (note, this is coming from a business publication) BCBS of Illinois plans to drop all of its PPO plans on the health care exchanges as of January 2016. These are the plans that cover many of the providers and therapists who see children with special needs.

Blue Cross is encouraging its customers to select either a Blue Choice PPO plan or a Blue Cross HMO plan in place of the PPO plans. The problem is that Blue Choice PPO is currently not accepted by most areas hospitals and thus very few medical providers. Blue Choice also does not function like a typical PPO at present and does not provide any coverage for out of network providers.

Similarly, the Blue Cross HMO option does not offer the flexibility of a PPO for out of network providers. Very few individual health care providers, such as occupational therapists, physical therapists, speech/language pathologists, and mental health providers (psychiatrists, psychologists, social workers, and counselors) are part of the HMO plan, as it pays so poorly that they cannot afford to accept it.

There are already a limited number of mental health professionals and therapists who take any insurance. Lots of them don't, making it hard for middle class families to afford help. The insurance BCBS plans to offer to folks come January through the Affordable Care Act exchanges will make this situation worse, forcing families to change pediatricians and primary care doctors who are not covered by the new plan. Because only a handful of hospitals will accept these new plans, I guess the message is pay your premiums but don't get sick, as you will not be able to use your local hospital or the one where your doctor has privileges. Parents who have paid in good faith are now being told if their kids are hospitalized, there will be no choice of where they go and no access to the best care for their children.

This change by Blue Cross will most severely impact people who have family members with disabilities, particularly children who require many therapies (e.g., children with autism spectrum and other neurodevelopmental disorders, children with Down Syndrome, children with cerebral palsy). Research consistently demonstrates that intervention for children significantly improves their ability to function as adults and saves a great deal of money in the long term for their care. But BCBS will be effectively denying access to these much-needed therapies.

Starting in January 2016, Illinois workers who do not receive insurance from their jobs will have to choose between finding new providers who will accept a different plan (good luck with that) or risking bankruptcy to pay for the services they or their children desperately need. Paying out of pocket for the therapies children with disabilities require is largely unaffordable to families already burdened with huge expenses associated with the care of their children. Changing therapists or stopping treatment for kids with special needs is a huge deal. It should not be dictated by an insurance company looking to increase its bottom line.

Families received letters last week informing them of this change. If their children's providers will accept a different Blue Cross Blue Shield plan that pays them less, the kids and their parents win but the therapists lose a considerable amount of income. If their children's providers will not accept what amounts to a substantial pay cut, the kids will lose their therapists or their parents will lose a considerable amount of their family income. In either case, guess who wins? BCBS.

For now, folks who have the BCBS PPO plan through their employer are safe. But odds are employers may stop offering the plan because Blue Cross Blue Shield will be hiking the premiums so high. Supposedly, the Illinois State Insurance Board has already okayed this. The federal government also has to approve, and chances are it will. After all, who has the biggest lobby, BCBS or families buying insurance through the Affordable Care Act and families of kids with special needs?

In Illinois, as many as 350,000 folks who purchased their insurance through the exchange are being dumped. The most vulnerable will once again be hurt in the service of making a greater profit for BCBS. How much profit? Well, in California Blue Cross had its tax-exempt not-for-profit status revoked a few months ago because of "criticism over its rate hikes, executive pay and $4.2 billion in financial reserves." I hate to be a cynic, but I'm sure some folks are making money in Illinois as well.

Of course, the biggest losers will be the children. I'm talking about kids whose therapists or pediatricians can't afford to take much smaller payments from BCBS or another insurance company. Kids whose families can't afford to pay out of pocket and will have to drop therapies. And kids with special needs whose families were willing to pay higher premiums but were not given the opportunity. But I guess that's the point of insurance. You can use it, but not if life hands you a lemon and the insurance company needs to pay out more than you paid in premiums. Then, after years of paying your premiums, the company refuses to make lemonade and drops you.

This change, which came without warning to either providers or customers, is a good example of why healthcare should not be motivated by making profits. You can be sure Illinois is not the only state where this is happening. President Obama, this can't be what you intended when you fought so hard for the Affordable Care Act that bears your name.

I invite you to join my Facebook community and subscribe to my newsletter.