Not enough people dive into high-risk pools

Gregory Warner Apr 25, 2011

Not enough people dive into high-risk pools

Gregory Warner Apr 25, 2011

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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