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Not enough people dive into high-risk pools
A stethoscope wrapped around a roll of $20 bills represents the costs of health care.
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Kai Ryssdal: The Supreme Court said today it's going to take its sweet time deciding about the health care reform law. The justices declined to hear a case about whether or not the government can force people to have health insurance. While the lower courts do their thing, other pieces of the reform law are moving along.
One of them is the creation of something called high-risk pools -- insurance pools meant for people with pre-existing conditions who are considered high risk. Another way to say that is sick people who insurance companies usually try to turn away. The health care law set aside $5 billion to help those folks. But one year later, few people are taking that help.
From the Marketplace Health Desk at WHYY, Gregory Warner reports.
Gregory Warner: Jose Cortes was a Spanish teacher at a college in North Carolina until strange things started happening.
Jose Cortes: I was teaching one class and suddenly, I just lost my voice. And the students told me, "What is happening?" and I couldn't answer.
By the time doctors figured out why he'd been acting so strangely, he'd been fired. Lost his benefits.
Jose Cortes: And it happens that I have a tumor.
A frontal lobe brain tumor. And no insurance to pay for chemotherapy. At this point, Jose Cortes became what insurance companies call "high risk." No company would sell him a policy.
Anne Cortes: High risk. Very much so.
This is his wife, Anne. She says he had two options: Join her health plan at work, but that would take a year because of his preexisting condition. Or go on Medicaid -- but he'd have to pay the first $32,000 out of pocket.
Anne Cortes: Technically we qualified for Medicaid, but we wouldn't have any money to pay for the house or buy gas or anything like that!
She wasn't going to give up that easily. Every night she scoured the Internet.
Anne Cortes: And I saw something on a website that said, there's this high-risk insurance pool in North Carolina.
A high-risk insurance pool designed for people like Jose who had no other way to get coverage. This was 2009 -- before health care reform. So Jose applied. And he was denied.
Anne Cortes: They said that he had coverage available.
The insurance through her job that would take 12 months.
Anne Cortes: But if he didn't get treatment, he would be dead very soon.
So Anne sent in an appeal. And the appeal was denied.
Anne Cortes: And that was the moment that I just knew, we were just lost.
She'd hit a wall. And she wasn't the first. High-risk pools are run by the private insurance industry. They've always been expensive, and hard to qualify for. The new health law promised to change that. It set aside $5 billion for federally-funded high-risk pools that would be easier to access and more affordable.
Cecil Bykerk: The anticipation was that people would be knocking the doors down for these high-risk pools.
Cecil Bykerk runs high-risk pools in three states.
Bykerk: Social Security Administration predicted that we'd have almost 400,000 people by now. That hasn't happened yet.
Not by a long shot. The actual number at years end?
Bykerk: Somewhere around 10,000 to 11,000.
Experts aren't exactly sure why. Some say it's still too expensive -- premiums are $400 to $800 a month. Others say it's too exclusive. To qualify you have to have been uninsured for six months. But there's a third explanation for why some states are enrolling much faster than others.
Deborah Chollet: If the governor supports a program and does outreach, enrollment will jump.
Deborah Chollet is at the research group Mathematica in New Jersey. The high-risk pools enrolling the fastest are almost all in blue states.
Chollet: Remember, we're looking at people who have been shut out of the insurance market. So they're sitting out there thinking there's nothing for them and a governor makes a statement saying there is something for you.
Cecil Bykerk's seen this. He runs high risk pools in Montana.
Bykerk: In Montana, the commissioner who's a Democrat went around the state, got a lot of free press!
She got the high-risk pool enrolled 50 percent. But Bykerk also runs the high risk pool in Iowa, where despite a marketing blitz at Walgreens and on television, enrollment's stuck at 14 percent.
Bykerk: If your governor is making claims that this law is unconstitutional and it's gonna go away, you might be leery of buying.
Politics makes a difference in whether people know about the risk pool -- and whether they trust it. Which brings us back to North Carolina and Anne Cortes. After her appeal failed, she took a radical step.
Anne Cortes: I quit my job.
Jose Cortes: And we sell everything.
Anne Cortes: So that we could qualify for Medicaid.
And it worked. Jose is getting treatment.
Warner: Anne, do you remember the name of the person who denied your appeal?
Anne Cortes: Keough? Is that Michael Keough?
Michael Keough: My name is Michael Keough.
I found Mr. Keough. He's still head of the high-risk pool in North Carolina, and he said:
Keough: A case like what you describe, the Corteses? I think we'd try to look at that differently at this point.
Warner: So you're saying that if the Corteses had applied today they might have gotten a very different answer.
Keough: Yeah. Than what it sounds like they reported they got then. Yeah!
Warner: Why?
Keough: Oh, I'm not sure. Except that we're an evolving organization.
Keough and I went back and forth on this and finally he just said look, his interpretation of the legislation had become more open.
Keough: You take a statute and you try to interpret it, and the only way you're gonna learn how to do that is by actually having some real-life situations to implement it with.
Of course, a lot about this high-risk pool has changed since Jose Cortes was denied in 2009. The program his wife had to find on a website somewhere now has a marketing budget of half a million dollars. And its own Facebook account.
Keough: We have about 500 friends on our Facebook page.
And though he may not put it this way, you might say that Michael Keough's role has shifted. He's gone from the one guarding the gates to the one in charge of throwing them open, hoping more high-risk people will decide to come through.
In Philadelphia, I'm Gregory Warner for Marketplace.
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I am desperately looking for a way to be able to get Medical Insurance even though I have a "pre-existing condition," but I just cannot afford my state's premium. It has nothing to do with rather politicians are sounding supportive enough or not- please! I don't think we Americans have that type of luxury!
(And yes, I live in a Blue State not Red.)
People are jumping on Mr. Keough as if he was the one who wrote the law. Every comment made in this forum doesn't consider the qualifications. The High Risk Pool wouldn't have been available to Mr. Cortez. Qualifications include these two items that as of his termination he didn't meet: 1) YOU CAN'T HAVE HEALTH INSURANCE FOR SIX MONTHS PRIOR TO ENROLLING IN THE HIGH RISK POOL. 2) YOU MUST BE DECLINED FOR INSURANCE BY AT LEAST ONE COMPANY.
Supporters of PPACA won't tell you about these little details because it makes the entire program less valuable.
Mr. Warner should have actually done his research before pouring water onto this grease fire.
My heart goes out to the Cortes family. Unless you have the misfortune of being mis-diagnosed, or get faced with a catastrophic illness such as a brain tumor, you just simply won't understand. Jose's personality, executive functions, (judgment) and other things are affected greatly by a frontal lobe tumor, and so I'm sure that with that imperfect knowledge, perhaps (i am guessing here) mistakes were made, and in the aftermath of losing a job and possibly wanting to get a divorce, perhaps the call was to NOT get the highly expensive COBRA. Whatever the case, the TUMOR is the enemy, not the CORTES family. They tried to do all they could to receive help, but ended up losing everything in order to save Jose' life. I give my kudos to this brave and courageous family who have sacrificed so much because of an idiotic bureaucrat(Keough) who says, "duh,,,we are evolving, we just had to see what people really needed out there, and when the problems seemed too big, I shut the door on them". It's because of people like that that the Cortes family was forced to the extreme measures they did. God bless them with health and a happy future!!!
One thing that the people who hold the Cortes' in contempt for not taking personal responsibility seem to be missing is that the guy had an F'ing brain tumor in his frontal lobe. Seeing as how none of you have survived a brain tumor in the area that controls metacognition, you know, the part that controls your thought processes, or supported a person who is falling apart because he can't talk and doesn't know what the hell is going on and has lost his job because of it, a part of me wishes you could walk in his shoes and a part of me wouldn't even want that for you. It saddens me that the discourse about people who really need help in this country is defined by assholes who sell their souls for the privilege of providing corporate welfare to their unmonitored campaign donors all the while demonizing the truly needy for all of our budget shortfalls.
First, COBRA is temporary; a stopgap, usually only 18 months, 30 months under some circumstances. I was on it for two months after a layoff, and it devoured my severance. Second, the enrollment timeframe may be short; if you decide to check your other options, you could easily wait too long.
Likely, details like this were left out in the interest of brevity.
Anyway, sneering that the Cortes's were not willing to sacrifice ignore the fact that they liquidated ALL their assets to go on Medicaid. I had to spend down my mother's assets to get her into a nursing home for the last few months of her life, and there's not much left meeting Medicaid's requirements. Mom was going nowhere after her stay, but hopefully the Cortes's have some life left, even if they start over with nothing. It's not always the case that people want to game the system, sometimes it becomes clear that the system does some gamesmanship too.
1. So Mr. Cortes was fired. What about COBRA? You say his benefits vanished. COBRA is law. He should have had the option of continuing his benefits by paying the full premiums himself. The fact that you ignored this possibility is a gigantic, substantive omission. My guess is that Mr. Cortes didn't want to fork over the dough for the full premium. Nobody seems to think they should have to pay anything for health care anymore. We pay for food, clothing and shelter, don't we? People who provide healthcare to us make sacrifices in order to do so. They deserve to be paid for their services just like they dry cleaner does. So why don't people think they should have to put their skin in the game? People used to pay a bigger share of their own healthcare costs, and this was probably less of an issue back then. People are happy to fork over cash for their vacations, cars and flat-screened TVs, but for some reason they don't think they should have to make any sacrifices for their own health. That's not all people--just the people whose stories are always told in the mainstream media--and the mainstream media implicitly agrees.
2. Because Mr. Cortes had the COBRA option (by law) but they chose not to pay the full premium to continue his healthcare coverage and for Mrs. Cortes to quit her job so they could qualify for Medicaid. So they would rather have taxpayers bear the burden for the costs of his care than bear this burden themselves, when they probably could? The fact that you don't even address COBRA in this story is a huge, gaping hole and raises so many questions. So it's simply not complete. What ever happened to a patients' personal responsibility for their own health and healthcare?
This story was poorly produced, and as an avid Marketplace listener I expect better than this.
First, we began with the story of a couple, the husband has a life-threatening condition, and he is denied enrollment into North Carolina's high risk pool. Then, suddenly, we turned to how enrollment in the new high risk pools are lower than expected and varies based on the politics of the state. There is an implication that this low overall enrollment has somehow lead to denial of Jose Cortes in North Carolina, but this connection isn't made. In fact, the opposite seems to be true: that less high risk patients enrolled costs the program less, so there is no reason to deny someone from enrolling when there aren't too many people enrolled. The causal connection between lack of enrollment and Jose Cortes' case was simply not made, and it is shoddy journalism.
In fact, it would seem, as in the case of North Carolina, there may be many people like Cortes who are applying, but are being denied, despite their qualifications for the program. The real story is the reasons why he might have been denied and whether that denial was wrongful (which is what I suspect given Mr. Keough's subsequent comments).
Another comment; did anyone happen to notice that Mr. Cortes got fired BECAUSE he got sick? He had a safety net, then got it yanked out from under him. He and his wife ARE most definitely victims. And if health care had not been linked to employment, he might not have had to impoverish himself to get treated.
In addition, if Mr. Cortes survives, he will live to pay insurance for some time in the future, as well as do other useful things like teach again, etc. Had he just died from being untreated, it's a total loss for everyone. Further, reading between the lines, I don't find that he's just looking for someone to pay his bills, just for a chance to survive and maybe pay back the cost of his immediate needs.
It seems to me that this story brings up two important issues:
1. Someone who has been diagnosed with an expensive disease does not belong in an insurance pool. Insurance should be for those without known diseases. If we know someone has an expensive disease, it should be a matter of deciding who's to pay for treatment- other taxpayers or the individual.
2. I'm bothered that the individuals in this story are made out to be victims. What ever happened to personal responsibility? I believe that everyone should be required to have health insurance; we don't make auto insuarance optional. Insurance only works if everyone pays into it, otherwise it's a simple economic calculation that your better off letting taxpayers or other policy holders pick up the tab in the event you get sick.
Why didn't Mr. Cortes buy the COBRA coverage his employer was required to offer him when he was terminated? He could have avoided this whole situation, and the monthly premium probably wouldn't have been any higher than he's paying now. People make choices and when they don't work out, they want someone else to pick up the pieces.
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