Keeping Your Head Above Water in a High-Risk Pool

NOTE: The Affordable Care Act is often referred to as Obamacare. They are the same Act.

More often than not, when a bill dies in Congress (or is withdrawn due to lack of support), it is not revived until the next Congress. (There is a new Congress every two years.) However, healthcare reform is a big enough priority for the White House and Congressional Republicans that it appears lawmakers will continue to negotiate with various caucuses to find a passable solution as soon as possible.

Recently, after negotiations between moderate and conservative Republicans in the House, an amendment to Paul Ryan’s American Health Care Act was offered. The amendment would keep all of the Essential Health Benefits and several other provisions of the Affordable Care Act, but allow states to opt out of coverage if they could prove that opting out would keep consumer costs down, cover more people, or if it would be in “the public interest of the state.” There is no specific definition of what is considered “the public interest of the state.” Secretary of Health and Human Services Tom Price would be responsible for approving or denying state waiver requests.

How could the amendment affect you?

With a waiver in hand, a state could get rid of the protections for people with preexisting conditions by establishing high-risk pools. A high-risk pool is exactly what it sounds like: everyone considered a high-risk/high-cost patient is grouped together under less than favorable insurance policies. According to a 2015 analysis by the Commonwealth Fund, high-risk pools would do exactly what Obamacare was trying to prevent: increase costs to the population with the highest medical bills and/or severely limit the coverage offered to those in the high-risk pool.

High-risk pools are not new to health insurance markets. The Affordable Care Act banned high-risk pools, but before that, they were used in 35 states and as a stop-gap measure between the passage of the Act and when it went into effect. Evidence from previous high-risk pools supports findings that state-based programs, while charging high-risk patients up to 250% more than healthy patients, came with insanely high premiums and out-of-pocket maximums.

The government knows it would have to fund states’ high-risk pools. Currently, they plan to offer subsidies totaling $25 billion over 10 years. However, independent estimates place the figure needed to fully fund the pools at $178 billion. In order to control consumer costs at all, coverage offered to high-risk patients might be whittled down to nearly nothing at all.

There are document cases of patients in high-risk pools paying $18,000 and $25,000 premiums, even with limited coverage. According to the Center for American Progress, I could pay an additional $5,600/year. Even people with mild asthma could pay over $4,000 more than they do now. Patients with certain kinds of cancer could end up paying over $142,000 more, and pregnancy could cost up to $17,320 more.

What does this mean in practical terms?

The numbers are good to know, but they're cold. I started this blog hoping that eventually, I would be able to support myself with it. If the above reforms pass, that will become much more difficult. Finding an individual health insurance plan that will cover a diabetic woman who already has complications would be next to impossible for states with waivers, and if I do find one, it will be prohibitively expensive.

Will we have to choose which meds we can afford? Will we have to forego the best treatment because insurance policies are no longer required to cover it? 

The good news is, we can do more than just keep our heads above water. We can swim. Only 17% of Americans approve this plan (poll was taken before the amendment, which doesn't actually change anything in the bill), which is a number so low, it sure includes a majority of healthy people. A smart Senator or Congressman won't vote for a bill that is so unpopular in their district. However, to be on the safe side, we might want to make sure our lawmakers know how we feel about it.

Find the people who represent you in Congress and make a phone call. It's a right guaranteed by the First Amendment (petitioning the government for the redress of grievances), and you may be surprised how effective it can be.


Ten EHBs and A Provision

There's a lot at stake for us as our elected officials try to reform healthcare. We should all understand what it means when the newspapers say they are removing this or that requirement from a proposed bill, and since it appears that Congress will continue its efforts toward healthcare reform, I wanted to discuss some of the things that will make or break their efforts, things that will affect you, no matter what condition(s) you have, or even if you have no condition at all. (Read about the first effort to reform Obamacare here.)

It’s hard to believe that it’s only been seven years since Obamacare, or the Affordable Care Act, was passed. Before that, insurance looked very different than it does today. The main reason for that is that Obamacare mandated that certain things be covered in every plan. One of the things on the table is the removal of all the Essential Health Benefits (EHBs) in an effort to control costs.

This would control costs by severely reducing the number of people covered by insurance. Those people would not see a doctor as often, potentially losing control of their conditions, and would end up going to the more expensive emergency room as a result. (Emergency rooms can’t legally turn patients away, regardless of their ability to pay, and unpaid hospital bills default to the taxpayer.)

How many EHBs have you used over the course of your condition? (I will mark all the ones I’ve used.)

  1. Outpatient care – all your doctor visits where you don’t have to stay overnight.
  2. Emergency room visits
  3. Hospital treatment for inpatient care
  4. Prenatal and postnatal care -- maternity care preceding and after birth of baby. This is an important one because in the bad old days, pregnancy wasn’t covered at all. Since the majority of insurance policies cover ‘accidents and illness,’ and pregnancy is neither accident nor illness, it didn't qualify. Pre-natal wellness visits, blood tests, recovery, and more were paid for out of pocket. Not to mention that the baby sometimes wasn’t covered for the first 10 days, so that if there was something wrong, it would be classified as a pre-existing condition, which is also not covered.
  5. Mental health and substance abuse services, drug and alcohol rehab. This is the rule that helps people with opioid addiction and veterans with Post Traumatic Stress Disorder.
  6. Prescription drugs – no explanation necessary.
  7. Rehab and rehabilitation services and devices -- to aid in recovery in case of injury, disability or chronic condition, including physical and occupational therapy, speech-language pathology, psychiatric rehabilitation, and more.
  8. Lab tests
  9. Preventive services, including counseling, screenings, and vaccinations and care for managing chronic disease – annual physicals, Pap tests, mammograms, colonoscopies, etc.
  10. Pediatric services, including dental and vision for children.

That's nine out of 10 for me.

Now the provision that pulls it all together, because even if you have access to all of the EHBs, if they're too expensive, access doesn't matter. The 'community rating' provision of Obamacare says that people with pre-existing conditions don't pay more for coverage than their healthier peers. It says that no one in a set geographical area (community) can be charged more than anyone else in that area for the same amount of healthcare coverage, regardless of circumstances like gender, occupation, industry, weight, claims history, or most important to us, health status (pre-existing conditions). Right now, the only factors an insurance company is allowed to consider are family size, age, geographic location, and tobacco use.

In a relatively short time, these regulations have become important to us. They allow us a higher quality of life. How much more would you have to pay for your condition if the EHBs and community rating provision were eliminated? If you feel strongly about keeping the above provisions, tell the people in charge of the reform effort, and not just on Capitol Hill. Rumor has it, some states are moving forward without Washington.

(Here is a link to Project Vote Smart, which will tell you who works for you, from the president right down to local judges.)