When the health insurance premiums got to the point that they were higher than her mortgage, Renee Powell started to become cynical.
"There was something in me that just kind of switched," said the mother of two from Bartlesville, Okla. "I was OK with paying $750, but when it became about $100 more than my housing costs, it upset me."
Powell is an epidemiologist and used to work for the state in Oklahoma City. She had affordable insurance through that job.
But when her husband graduated from dental school, she stopped working, and the family moved to their current home, about 10 miles from the Kansas border.
She shopped for insurance through the Obamacare exchange and learned that rates in her new area were much higher than they had been in Oklahoma City. She bought a health plan from Blue Cross and Blue Shield of Oklahoma for $750 a month with a manageable deductible.
Then last year Blue Cross eliminated that plan — which is pretty common as insurers adjust to the Obamacare markets — and Powell was forced to buy the more expensive policy with a deductible of $3,000 for each person in her family. The insurance pays for checkups and prescriptions, but if anyone gets sick, Powell has to pay the full doctor bill until the deductibles are met.
Insurance Just Isn't Enough
While the Affordable Care Act managed to bring basic health insurance to almost everyone in the country — about 90 percent of Americans are covered — for many people it's not enough.
Rising deductibles and copayments can mean people don't get much benefit from paying monthly premiums. A recent study from the Kaiser Family Foundation shows deductibles rose about eight times faster than wages in the past 10 years.
That's taking a toll on people like Powell, even though they have insurance.
"The nature of insurance has been changing over the last decade, to the point where people's out-of-pocket costs are becoming a real struggle," said Larry Levitt of the Kaiser Family Foundation. "More people are insured, but in many ways people are not insured enough."
High-deductible plans like Powell's, he said, are now the norm.
Powell has spent about $4,400 so far this year in premiums for that Blue Cross policy, and she said the plan has only paid a few dollars for antibiotics one of her boys needed when he was sick.
"I felt like we were paying money to the insurance company so that they could just sit on it and put it in stock," she said.
Now she and her husband are planning to buy insurance through his dental business, which is over the border in Kansas, where, for some reason, policies are much cheaper.
Surprise Costs
It's not just individual policies that are getting costly.
Melody Simon, a biomedical research project manager who lives in Detroit, is struggling to pay her bills, even though she has insurance through her work.
Simon was born with a birth defect that has required her to undergo seven surgeries. She needs medication and physical therapy.
Her insurance seems generous on its face — moderate copays and a $1,000 deductible for in-network care.
But her costs are also shooting skyward, in part because she moved last year to Detroit from Austin, Texas, and her insurance plan isn't as popular in her new city.
"It takes hours to find a provider that's not an hour away, that accepts my insurance and can also see me for my particular condition," she said.
She found a good doctor — in network — who performed her most recent surgery in December. But when she went back to see him at a different hospital for a cortisone shot to ease the pain in her arthritic foot — something she'd done many times back in Texas for about $40 — she was in for a surprise.
"It was like I was going into surgery. They brought me into the operating room and everything. And of course in my mind I'm like, 'What is all this pomp and circumstance for an injection?' " she recalled. "Of course, I should have known it was going to cost something ... and it did."
It cost her $832.96.
Simon's recovery from her December surgery has not gone well, and she's out of work on disability — which means she's only getting about 60 percent of her former salary. She's become totally dependent on her partner to get to physical therapy appointments and pay her bills.
Now they've decided to get married, just so Simon can get on her partner's health insurance, which is more generous than her own.
She said she hates the fact that they've made such a big decision for financial reasons.
"I don't think marriage should be an economic choice," she said. "It's pretty exciting, but I just wish this wasn't the circumstance that brought it about."
A recent poll from NPR, the Robert Wood Johnson Foundation and Harvard's T.H. Chan School of Public Health showed that 26 percent of people say health care costs are still a very or somewhat serious problem for them or their families.
Those rising costs are not providing people with a sense of better care. According to that same poll, 45 percent say the cost of their health insurance premium has increased and 35 percent say their copays and deductibles have risen in the past two years, even though just 16 percent say their benefits have improved during that same time.
And voters are concerned as well. Almost 20 percent of Democrats and 12 percent of Republicans ranked health care as one of their top two concerns in the upcoming presidential election, according to the Kaiser Family Foundation. The economy and jobs were the top issue in both parties.
The candidates for the White House have an array of ideas to deal with the issue:
Democrats
Bernie Sanders has proposed "Medicare for All," which would give everyone free access to health care — meaning out-of-pocket costs would disappear altogether.
But that would come with a price tag: tax increases of 2.2 percent for individuals and 6.2 percent for employers. The Sanders campaign says that would save most people a lot of money in the end, while shifting the burden of health costs to wealthy taxpayers.
But some critics — even many left-leaning economists — say his numbers don't add up and that the tax increases would have to be much higher.
Hillary Clinton's proposal builds on Obamacare, and some provisions attack out-of-pocket costs directly. Most significantly, she's proposing a refundable tax credit to cover costs that exceed 5 percent of a person's income. That could potentially help people like Renee Powell.
Clinton also proposes capping costs for prescriptions, trying to limit how much premiums can rise and protecting people from surprise bills like Melody Simon got after her cortisone injection.
Republicans
All three Republican candidates want to repeal Obamacare.
Donald Trump says he'll cut people's costs by allowing them to deduct the cost of insurance premiums from their taxes and to put more money in a tax-deferred health savings account to pay for health care expenses.
He also wants to allow insurers to sell policies in any state, rather than only in those states where they are licensed.
Ted Cruz is also a proponent of this idea.
Both candidates say the increased competition will reduce insurance premiums so people can afford better policies. But some say this could lead to lower-quality insurance because some states have lower standards than others.
John Kasich is proposing ways to cut overall health spending, which, he says, will lower costs for everyone. He's pointing to initiatives in Ohio where the state is changing the entire payment system — rather than paying for each service separately, the state is putting a single price on all the care needed for an illness. That means doctors and hospitals don't have any incentive to order excessive tests or medications.
Powell and Simon both said they don't expect much from these candidates.
"I think it would help for them to know just how much this costs and what families are going through," Powell said. "I'm slightly disillusioned with pretty much everybody in the race."
Editor's Note: Politics in Real Life is a new NPR series looking at issues impacting people's lives and how they match up with rhetoric on the campaign trial. Follow along and join the conversation on social media: #PoliticsIRL
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