The Alan Katz Health Care Reform Blog

Health Care Reform From One Person's Perspective

When It Comes To Health Care Reform, Nothing Is Easy

Posted by Alan on April 16, 2010

One of the most welcome elements of the health care reform package signed into law by President Barack Obama concerns the creation of high risk pools. For Americans with pre-existing condition who are unable to obtain insurance from the private sector and do not qualify for government programs like Medicaid, these pools are their only source for health insurance coverage.

According to an article by Sean Carr for A.M. Best Company, in 2009 35 states offered high risk pools enrolling roughly 200,000 people. To qualify for these pools, applicants have to first be rejected by commercial carriers on medical grounds. The coverage is more expensive than in the private market (not surprising since, by definition, the pool is made up of individuals with much higher than average usage and claims) and the benefits are leaner than generally available (to help keep the programs affordable). The Patient Protection and Affordable Care Act set aside $5 billion to establish new ones in states currently without them and to supplement existing programs. This aspect of health care reform is to take effect July 1st.

A safety net for those unable to get traditional coverage providing a bridge until exchanges are established in 2014. Whether you approve of the overall health care reform bill or not, this might seem like a good deal for $5 billion.

Well, not necessarily. For example, if you’re running for high office high risk pools can be an opportunity to score political points. And if you’re one of those 200,000 consumers already enrolled in a high risk pool, you might feel as if you’ve entered the Twilight Zone. And what if $5 billion isn’t enough?

There’s an underlying assumption, but not a requirement, that it would be state governments which establish these new high risk pools. But state governments are political beasts, so nothing is ever simple. So perhaps it’s not surprising that, as Mr. Carr reports, Georgia Insurance Commissioner and candidate for Governor, John Oxendine, has announced his state will not participate in the program in a letter, dated April 12th, to Health and Human Services Secretary Kathleen Sebelius.

Most “business mail” between government officials are boring, straight-to-the-point, well, business letters. This one is different. Commissioner Oxendine’s letter begins “I am in receipt of your April 2, 2010 letter detailing the first step in the recently enacted federal takeover of the United States health care system.” Not your typical opening for a formal inter-governmental missive. The letter then goes on to attack the Patient Protection and Affordable Care Act as a hastily drafted “government takeover of 17 percent of the United States economy, for being unconstitutional, and for eventually imposing an additional $1 billion burden on Georgia for Medicaid spending.

Commissioner Oxendine then questions whether the high risk pools, which are supposed to go away when carriers are obliged to accept all applicants regardless of their existing medical conditions will really be a temporary program. Consequently, he writes, “I cannot commit the State of Georgia to implement a federal high risk pool program that is part of a broader insurance scheme which I believe the Supreme Court will hold to be unconstitutional, leads to the further expansion of the federal government, undermines the financial security of our nation, and potentially commits the state of Georgia to future financial obligations.” He then ends his political attack on the health care reform plan Secretary Sebelius worked hard to enact as only politicians can: “With kindest personal regards ….”

My point for going into all this is not to comment on the merits of Commissioner Oxendine’s position (some of his arguments are overblown; some legitimate). Rather the letter strikes me as evidence that implementing health care reform – even the so-called “easy parts” – is going to be an extremely rocky road.

Keep in mind, Commissioner Oxendine’s letter does not mean Georgians in need will be denied access to a high risk pool. As Mr. Sean reports, the law allows HHS to contract with a qualified non-profit entity to run the pool if the state declines to do so. In this regard, Commissioner Oxendine is playing the equivalent of a candidate’s free card. He gets to use his state office to attack the federal government and the Administration’s health care reform plan without doing anything more than inconveniencing that federal government and some of his state’s citizens. What’s not to like?

Then there’s the coming Twilight Zone episode: Those enrolled in state high risk pools will be ineligible to participate in the new federally-funded program even though the coverage will be better than what they currently receive and less expensive than what they currently pay.

The reason, as reported by the Associated Press, is that only individuals who have gone at least six months without health insurance coverage are eligible for the federally subsidized high-risk coverage. Allowing the 200,000 individuals with coverage through state pools to move to the federal program would dramatically increase the cost of the new high risk pools. So unless they’re willing to drop their current coverage for six months (unlikely given that the high risk pool coverage is generally desperately needed to pay existing medical costs) current high-risk enrollees are “locked in” to their current coverage.

The good news, of course, if for the 375,000 people the Associated Press reports are expected to sign up for the new high risk insurance program. For them, the program could well be a lifeline that gets them to 2014 (when such programs will presumably be unnecessary) with their finances intact.

But will the $5 billion be enough to fund the program to 2014? Not likely. The federal pool will operate alongside existing state pools while HHS will create a national program to serve residents of states with no existing pools or who opt out of the program. Funding the program for nearly four years may prove a more extensive task than Congress has budgeted. The Associated Press article describes a letter from Medicare economists warning that “the program could go through $4 billion in its first year and run out of money as early as 2011.”

If correct there are three likely alternatives. Starting with the least likely:

  1. Require the states to pony up money (making Commissioner Oxendine a prophet).
  2. Reduce the benefits provided to enrollees and increase their premiums, making the federal high risk pool look more like the state versions.
  3. Pump more federal dollars into the program.

There are numerous moving pieces in the new health care reform legislation. High risk pools should be one of the easy ones. After all, high risk pools are a generally accepted, reasonably popular approach to reducing the number of uninsured Americans. As Commissioner Oxendine’s letter, the disappointment those in current state pools will feel, and the inadequate funding allocated to creating the new federal program all indicate, when it comes to health care reform, nothing seems to be easy.


3 Responses to “When It Comes To Health Care Reform, Nothing Is Easy”

  1. What we have is an entitlement program that this country can not afford. Rick K: Your Nevada is running a deficit because they are spending more than they can afford. It amazes me that our state and federal governments operate they way they do.

    Here is Arkansas we have a federal Senate race going. One of the candidates has said that he would look at benefit cuts to social security and now other candidates are jumping on him for that. Really, the only way to keep social security alive is to raise the eligibility age. There is no other way.

    We can’t spend more than we take in. Our government can’t even keep a health care entitlement program solvent, that gives benefits to just a portion of our nations population. Why would anyone think this new health care reform will work. It will fail and it could be the proverbial “straw that broke the camel’s back.”

  2. Rick K said

    As I sit here, read and think about this – I am not sure this isn’t such a bad idea. Albeit, the letter went overboard on the attacking of the program. However, he does make good points about this possibly turning into an “unfunded mandate” – and these types of mandates are causing havoc on state budgets across the nation.

    I live in Nevada – we do not have a high risk pool. We are also running a serious deficit with our budget. Most of which personally I blame on the public employees and their union contracts with the state and city governments.

    For the gravely ill – there is the HIPAA safety net, but the rules to obtain coverage require an individual to exhaust their COBRA coverage or come from a group that is too small to offer COBRA (state continuation). This is still extremely expensive – especially when we look at the “older” demographic.

    With state budgets being overstretched, why not just have a National High Risk Pool? Take the burden off the state and shift it to a National Program. Keep the six month wait and let’s see how the Feds manage the program. This is only for a few years, and it would give great insight as to how the feds can or can not manage the $$ associated with the program.

    Better yet – turn the High Risk Pool over to two national insurance carriers – let them administer the program and have the feds pay a 3% service fee above and beyond claims and admin. No marketing/sales – not necessary. Also, because the program would be employing very few federal employees – the overhead would be less than that of traditional government programs. The program would not have to abide by any state regulations therefore the states would not have to administer / field calls/issues regarding the programs – in addition, they would not be required to “promote” the program.

    Isn’t this what the feds are there for? The safety net for those who can not get protection on the open market?

  3. Gary Weiss said

    An underfunded mandate from the Federal gov’t? Who would’ve thunk it…??

    Yes, Mr. Obama, per your speech yesterday, we should be saying “Thank you”…for nothing!

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