16:28 PM

Is Health Insurance Worth it? Here’s the Math: Part 2



It’s the cost of health care that drives premiums. Here’s what you’d pay without insurance.

Health insurance is expensive, and we’ve all asked ourselves, “Is it really worth what I am paying?” This can be a nagging question if you happen to be young or in generally good health and not need much more than an annual check-up and flu shot.

The simple answer is “yes” — unless you are financially able to pay health care bills of tens or hundreds of thousands of dollars should your health take an unexpected turn for the worse. Even a quick, unexpected visit to an urgent care facility can quickly add up to more than $1000.

The Cost of Going Unisured: $5,353 average cost for an uninsured visit to a NJ Emergency Room, $16,561 average cost for a single overnight stay in a NJ hospitalBig Charges  By The Numbers

Millions of perfectly healthy people spend more time worrying about the health of their household budgets than budgeting for their health. But, we break bones. We become ill. We require surgery. And if the conditions are serious, serious medical bills can arise, and some could easily wipe out a family’s savings.

Consider “John Q. Smith,” a fictitious New Jersey man who breaks his ankle while playing tennis and is rushed by his family to the Emergency Room.

When John is billed for that ER, he could expect to see a charge for $5,3531 That’s the average charge for an ER visit at a New Jersey hospital, and doesn’t even include the charges for care John receives from ER physicians.

If John is admitted to the hospital for his injury, the charge for that admission is $16,561 per day. Time spent in the hospital varies based on the patient, but an entire in-patient hospital stay in New Jersey averages $72,609 in charges.

Then, John’s charges can rise dramatically – by $20,000 to $30,000 per day – when he is seen by doctors and specialists at the hospital for the care of his broken ankle.

Insurance  The Right Medicine

A trip to the pharmacy can serve as a welcome reminder of how important prescription drug coverage is to Horizon members.

Prescription medications vary dramatically in price, depending on whether they’re offered by a specific pharmaceutical company (“brand name”), are a “generic” version (same active ingredients of a brand name drug) or are a “specialty” drug (created to treat specific or chronic conditions).

When you look at the ten “brand name” medications most frequently used by Horizon members, the average cost is $5032  per prescription. If your condition requires -- and your doctor recommends – that you go on a “specialty drug,” those can charges add up quickly.

The ten most frequently utilized “specialty drugs” among Horizon members range from $208 per prescription to $21,000, with the average cost for each Rx of $6,339.

Prescription drug costs are the fastest-rising highest health expense, and are growing at a faster pace than wages and inflation.

Absent the ability to pay for prescriptions, consumers face very hard decisions, including taking the meds they need less than directed and cutting back on groceries and other necessities so they can better afford their drugs.

Value Defined: Peace of Mind, Health and Wellness

With an insurance card in their wallet, consumers can be confident knowing that they are protected from catastrophic costs of being sick. But, just as important is knowing what the coverage buys in order to stay well. Coverage starts with “Essential benefits” (which come with every Affordable Care Act –“Obamacare” – policy), and they include ten elements:

  • Ambulatory patient services (outpatient services)
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services (those that help patients acquire, maintain, or improve skills necessary for daily functioning) and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care

For a full view of what your Horizon coverage offers you and your family, log into Member Online Services or the Horizon Blue App.

 All charges based on 2020 Horizon claims data.

All pharmacy data based on 2020 Horizon claims, blended retail and mail order.