Sick and Tired of Being Sick and Tired

The most sympathetic parts of the embattled healthcare reform deal with folks who are already sick, people insurance companies like the least. Risk-avoidance has been a cornerstone of managing health insurance companies to maximize profitability (and almost 1/3 of all American healthcare dollars go for administrative and insurance cost, not direct medical costs; the statute’s goal is to reduce that to 15%): “Health care expenditures are highly concentrated with the most expensive 5% of the population accounting for half of aggregate health care spending, whereas the bottom 50% of spenders account for only 3%, which means that insurers' gains to be had from avoiding the sick greatly outweigh any possible gains fro m managing their care. As a consequence, insurers’ resources have been devoted to such avoidance at a direct cost to effective care management which is against the interests of the insured.” Wikipedia.

The underlying philosophy of the legislation is that by requiring everyone to be covered, there is a larger pool over which to amortize the costs of America’s sickest people. Of necessity, this makes healthier people bear some of the burden of those who place the heaviest burden on the system, but without this balancing effect, the entire reform package fails.

The massive healthcare reform legislation carries with it gradual implementation over time. Today, if you have a preexisting condition and go to a new insurance carrier, you have to disclose that condition and the carrier can deny you coverage or charge such a horrific premium that it is an effective denial of coverage. Under the new law, preexisting conditions can be considered by insurance companies until January 1, 2014 – three years from now. While lifetime benefit caps and the ability to drop insured patients who are currently ill but costing insurance companies too much have been eliminated, the plight of those who are chronically ill – especially those whose illness carries expensive lifetime or long-term treatment options – is otherwise muddy at best. And without insurance, people who are really sick face medical bankruptcy.

Congress created an interim step to cover people who are already ill until the implementation of the above-noted 2014-date section of the law through offering coverage through (state or federal) subsidized pooling for folks who have been uninsured for at least six months (the sneaky, last-minute impact of a strong health insurance lobby): “These so-called high-risk pools were included in the new healthcare law to provide relief for some of the most desperate uninsured Americans until 2014, when insurance companies will be required to cover everyone regardless of medical history.” Washington Post, July 1^st. While the Administration thought they would receive a flood of applicants to this benefit, the reaction has been underwhelming: “In the spring [of 2010], the Medicare program's chief actuary predicted that 375,000 people would sign up for the pool plans by the end of the year. Early [in November 2010], the Health and Human Services Department reported that just 8,000 people had enrolled.” Washington Post, December 27^th. Why?

“State-level directors of the plans … said that the insurance premiums are unaffordable for some who need the coverage - and that some would-be customers are skittish about the plans because federal lawsuits and congressional Republicans are trying to overturn the entire law.” The Post. (See below) If someone has inferior coverage, but coverage none-the-less, why would they risk entering the insured high-risk pool... which requires that they drop out of their feeble coverage for six terrifying months! What if they need treatment during that six month period? This is even riskier if that pool is high on the list of legislation to be repealed by the political party that made the most gains in the mid-term elections? Potential beneficiaries see themselves losing those benefits, having to reapply to existing insurance companies, who would (without the benefits of the 2014-implementational sections of the bill) have the right to deny coverage because of the preexisting condition. Catch 22.

Without these provisions in the law, chronically-ill Americans who aren’t covered by large company plans that contractually prevent termination or wealthy enough to cover their healthcare costs (and who of us really can afford such extraordinary costs?) are simply expendable; there are no provisions to protect them from the catastrophic costs of healthcare. Nevertheless, perhaps because this seems to be one of the few issues that Tea Party and traditional Republicans can agree on, the GOP has announced clear plans for 2011 to repeal the healthcare reform legislation any way they can and quickly as possible: “Rep. Fred Upton (R-Mich.), incoming chairman of one of the House committees that oversees health policy, said undoing the Democrats' health reform law would be a top priority for the new GOP-controlled Congress… Upton said on ‘Fox News Sunday’ that he believes there may be enough opposition in the new House to reach the two-thirds majority required to override a presidential veto. Short of that, he said House leaders will ‘go after this bill piece by piece.’” Washington Post, January 2^nd.

Even if this legislative push doesn’t work, and if the cornerstone of the Republican 2012 presidential campaign platform remains repeal of “Obamacare,” why would chronically-ill Americans take a chance to opt into a high-risk pool? Funny thing about healthcare; you don’t want to pay for it until the day your very survival and quality of life depend on it. And for many payment-averse Americans, that day will come.

I’m Peter Dekom, and sympathy and empathy are hard to come by in economically-impaired times.