The Washington State Health Insurances Plans – Comparison Report is the second report produced from an ongoing research collaboration between the Tubman Center for Health & Freedom and Byrd Barr Place and follows the WELL US Study released in 2022.  

Before stepping into the door of a clinic – before even making an appointment – we worry about how we will pay for our care. For those with health insurance1, we end up navigating through complex benefits booklets, online portals with broken links, or listening to hours of elevator music waiting to speak with a service representative. While many insurance plans talk about promoting health justice and access to care, the reality is that the experiences of our communities often do not align with these publicized stances. That is why, in Tubman Health’s latest research report, Washington State Health Insurance Plans – Comparison Report, we investigated each insurance plan’s current practices and policies to compare which plans are actually uplifting the health and wellbeing of those they serve. 

In this comparison report, Tubman Health builds on the work from the WELL US Study that identified key health needs of marginalized peoples in the Puget Sound region and how these individuals & communities remain resilient despite the barriers to health(care). One of the key findings from WELL US was that members of marginalized communities tend to utilize Complementary or Alternative Medicines (CAM)2. However, a key barrier to accessing this care was health insurance – namely the way in which current insurance practices, with their limited coverage and high deductibles, compounds high costs of care. To build upon and clarify these findings, in Washington State Health Insurance Plans – Comparison Report, Tubman Health explores the following questions:

1) Do Washington State health insurance plans support access to methods of care which are preferred by marginalized community members?
 
2) How do various Washington State health insurance plans support or threaten Tubman Health’s model of care?

Insurance Practices & the Cycle of Marginalization 

Systemic Racism, which manifests at the inter/intra-personal level as experiences of medical racism and racial weathering & stress respectively, results in communities seeking Complementary or Alternative Medicine (CAM) as a pathway to healing and wellness. Often times, these modalities have been passed through family lineages and cultures – meaning they are the culturally appropriate care modalities that our people feel most comfortable and familiar with. However, current insurance plans & practices, including the limited in-network provider list, visit caps & limits, and denial of many CAM treatments results in major hurdles to wellbeing for Black, Indigenous, and other marginalized communities.  

Comparison Criteria 

Plans were rated against each of the seven criteria after a secondary review of each plan’s overview documents and primary data collection through phone calls with the insurance company agents. Our network comparison focused on acupuncture as a proxy modality to represent CAM and included in-depth reviews of the following Apple Health Medicaid Managed Care Plans: 1) Molina Healthcare of Washington, 2) Community Health Plan of Washington, 3) United Healthcare Community Plan of Washington; as well as the following Marketplace Exclusive Provider Organizations: 1) United Healthcare of Oregon Individual and Family Affordable Care Act Marketplace Plan, 2) Premera Blue Cross Individual and Family Affordable Care Act Marketplace Plan.  

Insurance plans in this study were graded against seven criteria with scaling benchmarks going from high coverage/access to low coverage/access. After the assignment of these seven criteria points, an overall rating was calculated. Comparison criteria were selected based on evidence-based best practices for promoting access to health care among marginalized communities pulled from peer-reviewed literature, as well as results from the WELL US Study. The criterion benchmarked in this study are listed below: 

1. Is alternative medicine covered? 

1. Does the fine print indicate true access to alternative care? 

1. Do visit limits for acupuncture create barriers to care? 

1. Are relationally-driven services covered/provided? 

1. Are transportation supports in place? 

1. Is gatekeeping used? 

1. How accessible is plan information? 

Together, these criterion measure not only the existence of policies that support care access, but the actual implementation and utilization of the policies in practice. This measurement of practices was crucial to our study, as Tubman Health’s inquiry seeks to understand not only what is on paper, but what our communities experience when seeking to activate their benefits.  

Key Findings from the Washington State Network Comparison 

Overall, the insurance plans reviewed showed a trend of exclusionary policies and practices related to Complementary or Alternative Medicine (CAM) regardless of the evidence-based support for cost-effectiveness and community reliance on these CAM treatments. This is especially troubling for the Apple Health Medicaid plans that cover adults with incomes up to 138 percent of the federal poverty level; 138% of the FPL translates to $18,754 annual income for a single person and $38,295 for a four-person family. Our findings clearly illuminate systemic barriers to health(care) for low-income individuals and families, contributing to a cycle of ill health and poverty. While the benefits cliff among public assistance programs like Medicaid continues to economically depress low income individuals, even for those with benefits, coverage for preferred methods of evidence-based treatment remain unavailable and inaccessible.  

For Medicaid plans that do promote coverage for CAM, the fine print leaves patients in limbo with broad, indistinct language such as “limitations may apply to these services”. Even after navigating the fine print, insured individuals often find visit limitations (maximums) and in-provider network requirements. These in-network providers are often shrouded by gatekeeping in the form of multiple required referrals and prior authorization. Our findings point to the difference between benefits in theory and benefits in practice. Without the implementation of practices, transparency of information, and comprehensive coverage, individuals on Apple Health end up paying a much higher proportion of their incomes on out-of-pocket healthcare expenses. This finding follows other findings from the Kaiser Family Foundation in access and affordability; “compared to higher-income people, those with lower-incomes spend a significantly higher share of their income on health premiums and out-of-pocket expenses”.  

For the two private plans that were part of this comparison study, both insurers performed even worse than the Medicaid plans on key access metrics, despite the larger total net incomes generated by the private plans. In Washington State, Kaiser Family Foundation found that the Average Gross Margin Per Member Per Month on the Individual Market has steadily increased in the last decade, from $420 annually per individual in 2011 to a peak of $1812 annually per individual in 2019 – a fourfold increase in less than a decade. Even during 2020, the start of the COVID-19 pandemic, private insurers in Washington profited an average of $1488 annually per individual insured in 2020. The Economic Opportunity Institute estimates that almost 3 million Washingtonians are on private insurance; this means that the private insurance industry made a ballpark gross profit of $4.464 billion dollars in 2020 while many individuals, small businesses, and communities were facing economic ruin.  

In the same year, 2020, Axios found that the CEOs of 178 healthcare companies made record $3.2 billion as a group. To further highlight this fiscal trend, health insurance CEO salaries have been at record highs, with STAT finding just last year in 2022 that seven of these CEOs, including those of the plans analyzed by this report (i.e. Molina Healthcare, UnitedHealth Group), made a record $283 million. In the same time frame, the Washington Department of Health reported that the COVID-19 death rate among Black populations was twice as high as white populations. What if our communities had access to the type of care they trust and prefer? Would the numbers and disparities be the same? 

Paired with the broader environmental considerations, the overall findings in our study paint a picture of the major gaps and disparate practices in the system as a whole. We feel these gaps and our communities feel these gaps as we search for insurance – we navigate through plans that may lead in one area, such as transportation supports, while faring adversely in another field, like access to alternative care (again as our comparison study found). This begs the question, with such high profit margins for insurance companies why do our communities have to trade off crucial benefits when selecting a health insurance plan?    

Our Next Steps 

Our findings on health insurance negatively impacting access to health(care) point to symptoms of a larger systemic diagnosis. We recommend that insurance plans read through this report and find opportunities to decrease barriers to care for our communities with immediate implementation. For organizations and insurance plans that promote health equity as part of their mission, parity in practice is crucial.  

Here at Tubman Health, investigative work for health justice does not stop with this report. While we build toward our flagship clinic, we are also creating a novel healthcare model that speaks directly to the needs of marginalized communities. Tubman Health’s model operates within existing systems, while amplifying alternative modalities, like Complementary and Alternative Medicines, that better serve the healthcare needs of marginalized peoples.