People with preexisting medical conditions are stuck in high-risk pools until 2014


Patients with preexisting conditions tread water in high-risk insurance pools until 2014. (istock)
January 30, 2012

The 2010 health-care overhaul creates state-based health plans for those who have medical conditions that make them uninsurable in the private market. These “preexisting-condition insurance plans” (PCIPs) are intended to act as a bridge until 2014, when insurers will no longer be able to refuse to cover people with medical problems or charge them more than other consumers. As of November, about 45,000 people had signed up for those plans, far fewer than expected.

However, there is a much larger group, more than 220,000 people, who have coverage through 35 state high-risk pools that were in existence before the overhaul was passed. Because of restrictions in the new law, they can’t sign up for the PCIP plans, even though the coverage is often cheaper (thanks in part to federal funding) and more comprehensive. For these people, 2014 can’t come soon enough.

Chris and Kristi Petersen raise 600 antibiotic-free Berkshire hogs and grow hay on 75 acres near Clear Lake, Iowa. Their health insurer dropped them in 2008 because, among other things, the company claimed that Chris, now 57, had failed to report a preexisting hernia that he subsequently had surgically repaired and that Kristi, who’s 55, was shorter, and thus had a higher body mass index, than she had reported. Lacking other options, the couple signed up for Iowa’s state high-risk pool.

Together they pay $1,304 a month for coverage. Chris’s plan has a $2,500 deductible while Kristi’s is $1,000. The plans generally cover 80 percent of their medical bills.

Chris Petersen, who supported the health-care overhaul, nevertheless thinks the law failed him and his wife. “This is the biggest check I write out every month,” he says. “The new federal plan would have been a lot cheaper.”

If the Petersens had been allowed to sign up with the PCIP in Iowa, their combined premium would have been $958 for policies with $1,000 deductibles.

People such as the Petersens, however, are stuck between a rock and a hard place: To qualify for a PCIP, they must first be uninsured for six months.

Experts say this requirement was included in the law to discourage people in the existing state high-risk pools and other private insurance plans from doing exactly what they would do if better, cheaper coverage became available: switch plans.

It’s clear why they might be tempted. Premiums in the new pools can’t exceed rates for standard individual coverage in the state, while the high-risk pools in some states charge twice that. The new plans must also cover preexisting conditions immediately, in contrast to the older state pools, some of which exclude such coverage for up to a year.

“Much as everybody would like to drop [the six-month requirement], if you did you’d have to increase expenditures,” says Sandy Praeger, the Kansas insurance commissioner, who chairs the health insurance and managed-care committee of the National Association of Insurance Commissioners. Federal funding for the program through 2013 is $5 billion.

Although enrollment in the PCIPs has been far lower than originally projected, health-care spending by the individuals who have signed up for coverage has been much higher than anticipated, say experts.

“The people coming into the PCIPs act more like the long-term uninsured,” says Jean Hall, an associate research professor at the University of Kansas who co-authored a report about the PCIPs for the Commonwealth Fund. “They’re not accustomed to managing on a day-to-day basis; they’re accustomed to going to the emergency department when things get bad.”

Nine states have asked the Department of Health and Human Services for more money to fund their PCIPs in 2012. However, it appears the program won’t run out of money soon. Through the end of September 2011, just $386 million of the $5 billion allocated had been spent, according to HHS figures. (Some experts caution against relying too much on September spending figures, since enrollment has increased since then and claims may take months to clear.)

“As you would expect, some states have exceeded projections and others have not,” says an HHS spokesman. “We have the capacity to accommodate the needs of the program.”

For people who can’t get into the new plans, however, that’s small comfort.

Jill Judy and Mark Brown signed up for the Arkansas high-risk pool a few years ago when Mark’s benefits ran out after his retirement from a management job at a company that repossesses boats. Judy, 49, has mild cerebral palsy, which she hasn’t been treated for since she was a child, and Brown, 62, had an angioplasty 15 years ago and still sees a cardiologist.

Individual insurers wouldn’t cover them, so they ended up in the state’s high-risk pool. Although Judy says she’s grateful that she has coverage, it’s hardly ideal.

The premiums for the two of them come to just under $1,000 a month. But the plan has a $10,000 deductible and a $1 million cap on lifetime benefits. “People like my husband and myself are paying $12,000 a year for nothing,” she says.

She estimates they could get better coverage and save 30 percent in the Arkansas PCIP. “But we don’t qualify because we’re not willing to be uninsured for six months,” she says. “It’s screwy.”

This column is produced through a collaboration between The Post and Kaiser Health News. KHN, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health-care-policy research and communication organization that is not affiliated with Kaiser Permanente. E-mail: questions@kaiserhealthnews.org.

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