Transparent Health Group aids uninsured under Obamacare

Even under the best-case scenarios, Obamacare still leaves tens of millions of people uninsured. That’s where Betty Heiman comes in.

Ms. Heiman, CEO and founder of Transparent Health Group, doesn’t sell insurance. What she offers is a service in which people without coverage can walk into a doctor’s office with an appointment, receive a discount on health care, and know what they’ll be paying in advance.

That’s a far cry from how most uninsured people now access health care, which usually involves waiting in long lines in emergency rooms or clinics, followed by sticker shock when the bill arrives. With her service, called Transparent Healthcare, there’s no wasted time and no mystery about the cost, she said.

“You know what the price is before you walk into the provider office because we schedule the appointment for you. It’s very concierge-level care,” said Ms. Heiman. “You walk into the office, and instead of leaning over the counter with a waiting room full of people behind you, sheepishly saying to the 19-year-old receptionist, ’I don’t have insurance, can you help me out,’ you know that you have an appointment.”

Ms. Heiman knows from experience: She previously managed an MRI/Radiology practice, where she would see patients show up with cash but no insurance. Even the doctors didn’t know the cost of an MRI.

With Transparent Healthcare, “you know how much it is, and it allows for the first time the uninsured to be a health-care consumer and contract for care in the same fashion that this country runs on,” she said.

Transparent Healthcare comes as the latest private-sector response to what could be described as the unintended consequences of Obamacare. Many health-care companies have expanded to help consumers navigate the glitchy Healthcare.gov website, but Ms. Heiman’s approach may be the first aimed at serving those falling through the Affordable Care Act’s cracks.

“There’s a cottage industry because there’s mayhem and there’s chaos, and that creates opportunity in the business world,” Ms. Heiman said.

Her company is built on the Costco model: Clients pay a flat amount per month per household — in New York, it’s $39 per month — and receive access to the Transparent Health Network’s platform of doctors, dentists, pharmacies and telemedicine, with costs negotiated in advance using Medicare prices as a baseline.

The company, which went fully operational in January, serves metropolitan New York and New Jersey, with plans to expand to Atlanta, Florida and Texas.

What makes the numbers add up is the changing face of the uninsured under the Affordable Care Act. The expansion of Medicaid and income-based subsidies for policies on the government health-care exchanges mean that those without coverage are no longer the poor but the working class, many of whom cannot afford the rising premiums and higher deductibles offered on the exchanges. These are often the same people whose hours were reduced to meet the Affordable Care Act’s 30-hour cut-off for employer-mandated insurance, but still earn too much to qualify for substantial subsidies.

The Congressional Budget Office estimated in 2012 that as many as 27 million would be uninsured in 2016, while McKinsey and Co. put the number at closer to 40 million.

That doesn’t include illegal immigrants, who cannot obtain health insurance from the Obamacare websites and often wind up depending on hospitals. Signing up undocumented workers for her service, she said, “benefits every single taxpayer not to have individuals sitting in an emergency room for four days because they think they might have strep throat.”

“We offer a method where people can get care with dignity in a way that includes price certainty and price transparency. We can actually make a difference in those who are transitionally and permanently uninsured in this country,” she said.

Then there’s what Ms. Heiman describes as the “functionally uninsured,” those who may have insurance coverage through their employer or the exchange, but whose monthly premiums are so high that it leaves them with little money left over to visit the doctor.

If they’re young and healthy, she said, it’s unlikely they’ll ever meet within the space of a year their deductibles, which means they pay the maximum under their policies for medical expenses.

“We’re also in an economic time when you see an increase in freelancers, an increase in 1099 individuals, who are also not required to be covered under an employer’s insurance policy,” Ms. Heiman said. “Maybe they’re working three jobs part-time instead of one job full-time. They can’t afford with their post-tax dollars to purchase a product on the exchange because when you get to a higher income level, the subsidies are very minimal.”

Transparent Healthcare’s clients include some small businesses who want to offer some coverage to their staff even though they fall below the 50-employee mandate. In New York, companies pay $29 per employee per month, which covers everyone in an employee’s household.

At the same time, Ms. Heiman stresses that the network is not a substitute for health insurance, for one key reason: The service doesn’t offer coverage for catastrophic care.

“It is certainly not a replacement for insurance because you bear all the risk,” Ms. Heiman says. “But when insurance is not an option, that doesn’t mean that you shouldn’t have an option. We like to look at ourselves as third option on the table.”

The Healthcare.gov website’s 2015 enrollment period opened Nov. 15 and runs through Feb. 15.