Monday, June 15, 2009

My fiance's travails with health insurance

My travails with health insurance are unpleasant. My maximum out of pocket liability will be quite high if I take a bare-bones plan that we can afford. However, as I mentioned, I am insurable.

My fiance is not. Her asthma and depression are under good control with medication. However, in the individual and small group markets, people must go through medical underwriting in most states. That means that insurers assess your health status and raise your rates if they determine you will cost more. If you have two expensive chronic conditions, they'll deny you.

Kaiser, which I seriously respect as an organization, denied my fiance individual insurance. Frankly, there is a sound business reason for doing so. In a market where you can underwrite, if Kaiser allowed the sick people onto its plans and other insurers didn't, Kaiser would eventually get all the sick people. Other plans would attract the healthier people by charging less. Kaiser would have to raise their rates for everyone in the individual insurance pool. That would start driving people out, most likely starting with the healthiest members who feel they can take their chances, which would raise everyone else's premiums, and then Kaiser would eventually have to drop that line of business. So, while it's wrong and inexcusable of them to do so, they have no choice from a business perspective.

Ironically, her chronic conditions are under control with medicine under normal circumstances. However, stress makes it harder to control these conditions. Not being able to afford medications would do the same.

In the US, insurance market regulations differ by state (the exception is large employers who hire people in multiple states; they are allowed to self-insure regardless of state regulations and contract with an insurance company to administer their plans). New Jersey, for example, has what is known as community rating and guaranteed issue in the individual insurance market. The former means that people cannot be charged premiums that differ by health status (strictly, community rating means that everyone pays the same premium, but often premiums can vary by demographic factors like age and sex). The latter means that everyone who applies for health insurance must get it regardless of health status.

These regulations sound good for consumers. However, once sick people can get insurance and get charged lower premiums than their health status would otherwise dictate, they will be more likely to get insurance. That drives up costs for everyone in the individual market. Again, that causes the healthier people to decide they'd rather take their chances and drop insurance. In New Jersey, the lowest quote I could get for individual insurance is $128.91, compared to $52 in Maryland. The individual market is not working well in New Jersey.

Anyway, this leaves my fiance in a very bad spot. We are between states, but once we are eligible for Maryland residency, she'll be able to enroll in the state's high risk pool. Some states have high risk pools, which insure people who are denied coverage elsewhere due to health reasons. This sounds like a good deal, but high risk pool coverage is expensive. The absolute cheapest option will cost her nearly $100 a month for very poor coverage (i.e. high cost sharing). Additionally, all high risk pools in the states that have them need to be subsidized. Lastly, I've heard a friend who has a chronic illness complain about the quality of the care she got with the state's high risk pool administrator, CareFirst.

The McCain solution to health reform was to increase funding for high risk pools. That's still costly and it still doesn't guarantee quality care. High risk pools are small by nature, which means higher administrative costs in proportion to larger plans. They're a bad deal. It would be better to require to get everyone insured under a mandate plus subsidies. That way, the healthier can subsidize the sick. Some people don't like that, but you're doing so already - doctors, hospitals and economists generally agree that the general public pays indirectly for the cost of care delivered to the uninsured both through higher insurance premiums and charitable donations.

In my fiance's case, until we can get her on that crappy plan to limit her out of pocket liability if she does have an accident, she'll just have to be very very careful. Additionally, we have to be extra diligent about seeking out low cost options like community health centers, other low-cost doctors with sliding scale fees, MinuteClinics and medication assistance programs.

I was prescribed a nasal steroid spray for allergies; I'm going to lie to my doctor that I need that prescription extended so she can use it. I figure in this economy, God will forgive me. Additionally, as I said, the actions of the insurance industry have been execrable. This includes Kaiser Permanente, which is otherwise an exemplary organization. What goes around, comes around - I know a lot of young adults are probably doing this these days.

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