In 2008, a Harvard Medical School study found as many as 11.4 million working adults in the U.S. who suffered chronic conditions were uninsured, many of whom had forgone medical care. -- Reuters
The high-risk health insurance pools are part of the Patient Protection and Affordable Care Act. They are up and running now in all 50 states, and are supposed to help some of these 11.4 million people -- those insurance companies had rejected because of pre-existing conditions.
With this large number of potentially eligible people in mind, many criticized the funding of the PPACA's high-risk insurance pools as woefully inadequate:
... government economists projected as recently as April that 375,000 people would gain coverage this year, and they questioned whether $5 billion allocated to the program would be enough... -- Associated Press
Yet, if you pay any attention at all, the stories you see go like this:
California, which has money for about 20,000 people, has received fewer than 450 applications, according to a state official.
The program in Texas had enrolled about 200 by early September, an official in that state said.
In Wisconsin... they've received fewer than 300 applications so far, with room for about 8,000 people in the program.
Coverage under the plan began Friday, with only five people enrolled.
And in Michigan:
PHP has mailed more than 1,300 applications to potential customers...
Nearly 100 people had turned in applications as of Monday, said Scott Wilkerson, PHP's president and CEO.
In fact, here in California, the program was so in need of applicants that they actually called me up to ask why I had not returned my application form (I had requested one just to see what it looked like and what the terms and conditions were, as part of my ongoing interest in the high-risk pool program. Fortunately I am able to obtain insurance otherwise).
There is one notable exception, Pennsylvania:
While other states have reported their high-risk plan applications are trickling in, Pennsylvania's response to PA Fair Care has been brisk. Applications are available online and about 3,000 individuals have applied so far. There is room for 3,500 in the first roll-out of the program.
What is going on? It is unlikely that most of those 11.4 million working adults who do in fact qualify for the high-risk pools up and moved to Pennsylvania just in time for winter!
It turns out that Pennsylvania's high-risk pool program does something none of the other 49 state or federally run programs do: The premium is not dependent on age. It is fixed at $283/month for all, with a $1,000 deductible and a $5,000 out of pocket limit.
Compare and contrast:
In many states, people in their 40s and 50s face monthly premiums ranging from $400 to $600 and higher. "I think there's some sticker shock going on," said Sabrina Corlette, a Georgetown University research professor. "People who may be eligible are finding out that even if they can get the insurance, the price is too high." Pennsylvania, which set a premium of $283 for all ages, has had no problem getting applicants.
And that's just the premium. In general, deductibles are higher (normally $2500) than in PA, and out of pocket can, by law, be as high as $5950. Sure, Pennsylvania may end up having the opposite problem of the rest of the states: not enough money to cover all those who would like to participate. If that happens, federal law gives them the option of raising prices or restricting enrollment. But far better to help out as many people as can be helped, rather than not enough.
Along with the typical pricing schemes that go up with age, there are many restrictions written into the law that are partly responsible for the dirth of applicants. Some of those are:
A barrier may include requirements that people be uninsured for at least six months and that people provide documentation that they've been turned down by an insurer. "There are many people who don't meet the criteria for the federal pool, particularly the six months without coverage," said Goldman. (Associated Press)
- In states where the federal government runs the program directly, the insurance plan doesn't provide coverage for prescription drugs until people have met a $2,500 annual deductible. "Applying this high ... deductible to the pharmacy benefit is a real barrier to consumer access to medications," Steven Browning, a Texas official, wrote HHS last week. (Associated Press)
- In Michigan, "So far, the biggest issue has been incomplete application forms. PHP is requesting a check for the first month's premium along with the application."
In fact, even a Republican Governor went so far as to request a waiver of the six-months coverage rule:
Saying federal regulations have created a "stone wall" preventing Connecticut residents from enrolling in a new state health insurance plan, Gov. M. Jodi Rell has asked U.S. Health and Human Services Secretary Kathleen Sebelius to consider relaxing the rule.
... Rell said enrollment could be limited because of the federal "crowd out" rule that requires a person be uninsured for at least six months before joining the plan....
"Implementation of such a restrictive, no-exception crowd-out/waiting period policy seems to contradict the stated goals of providing access to health insurance for those individuals with pre-existing conditions," Rell wrote to Sebelius.
Except that there is nothing Secretary Sebelius can do about it (AFAIK). Congress enacted the law, and the law says that people must have been without insurance for six months before they become eligible. That doesn't seem like there's much room for regulatory interpretation.
In a sane world Congress, noticing this problem, would consider amending the bill to allow for more coverage. In a sane world, Congress might:
That's some of things Congress might do, if it weren't impossible for Congress to do anything other than pick it's collective nose while waiting around to fail to invoke cloture, that is.
There is one thing that Secretary Sebelius, in charge of the 23 Federal programs, and those state officials in charge of the various state-run programs, could decide to do regardless of Congressional inactivity: change the programs to use fixed-premium pricing regardless of age, as Pennsylvania is doing, thereby lowering premiums down to a semi-affordable level for those most likely to be applying.
I have no idea whether such a concept is being considered, but in light of Pennsylvania's success and many other states' failure to attract applicants, it's something that should be seriously considered.
Let there be no mistake: for those who are being helped, the high-risk pools are an awesome thing:
Preschool teacher Gail O'Brien, 52, was uninsured and facing cancer treatments that would have left her family deeply in debt. She now pays $495 monthly for a plan with a $5,000 annual deductible. She has a type of immune system cancer, and just one chemotherapy treatment runs to $16,000.
Lives are being saved, treatments are being covered, bankrupties and financial disasters are being averted. But the program is capable of doing the same for a whole lot more people if there was a will out there to make it so.