WASHINGTON -- More than 100,000 of the sickest people in the health insurance market will have to switch to new coverage next year as the federal government and states close down special programs for individuals with pre-existing conditions.
Starting in 2014, the Affordable Care Act forbids health insurance companies from turning people away because of their health conditions or medical histories and from charging them higher rates, making a hodgepodge of government-funded health insurance plans called high-risk pools effectively obsolete.
Three-time breast cancer survivor Mary Duffy, 64, has been enrolled in a federal high-risk pool since its launch in 2010, and she's anxiously anticipating her transition to a new insurance policy next year. "I feel like I've got one leg on the bank of the river and one on the boat floating out," she told The Huffington Post.
Although the market reforms enacted by President Barack Obama's health care overhaul will provide the sickest Americans with unfettered access to the private health insurance market for the first time, and will offer financial assistance to many of them, people like Duffy could face disruptions in their medical care, especially amid the troubled rollout of Obamacare's health insurance exchanges.
"That's the thing that keeps me up at night," said Tanya Case, who is the executive director of the Oklahoma Temporary Health Risk Pool, a federally funded program based in Oklahoma City, as well as chairman of the National Association of State Comprehensive Health Insurance Plans, a trade group that will dissolve next year. "Our focus as high-risk-pool executive directors is on helping our members transition."
The failed launch of HealthCare.gov, the federal web portal to the health insurance exchanges in Oklahoma and more than 30 other states, is impeding enrollment into health coverage for millions of Americans. Those who have the most serious health problems are especially vulnerable to gaps in coverage, which could interrupt their medical treatments and expose them to huge bills.
Olivia Grey Pritchard, 32, is holding off on visiting HealthCare.gov to find a replacement for the federal high-risk-pool coverage she obtained in 2012 after being rejected by other insurers because of a past surgery to remove a nonmalignant tumor. Pritchard couldn't get insurance on the open market even though she's healthy now, so she's been paying $193 per month for her coverage.
Between news reports about the balky website and her own friends having a hard time enrolling, Pritchard, who owns a photography business in New Orleans, has decided to give the Obama administration more time to repair the web portal before she tries to sign up. Like Oklahoma, Louisiana didn't create its own health insurance exchange, so residents are reliant on the federal system. "I'm annoyed, but I'm not freaking out," Pritchard said. "They'll fix it."
Thirty-five states have high-risk pool programs covering about 200,000 people that predate Obamacare, and 17 are eliminating their programs starting Dec. 31 or in 2014. Obamacare's federal Pre-Existing Condition Insurance Plan also provides benefits to about 100,000 people in all 50 states and the District of Columbia. It expires at the beginning of next year.
Republicans often say these programs are a better way of expanding insurance coverage than comprehensive reforms like Obamacare.
Yet historically these high-risk pools have attracted only a small fraction of people who weren't able to get insurance elsewhere, largely owing to inadequate funding, high premiums and barriers to enrollment, said Karen Pollitz, a senior fellow at the Henry J. Kaiser Family Foundation in Washington, D.C. Some state-run plans even exclude coverage for a period of time for the health conditions that drove people to the high-risk polls in the first place, she said. "They were a safety net, but a pretty unreliable one that helped not that many people," she said.
People moving from the high-risk pools into the health insurance exchanges in most states will have many more choices of health plans, and will gain access to new subsidies. High-risk pool coverage also typically comes at prices around double what healthy people pay and requires patients to cover a lot of their costs out of pocket, like meeting deductibles as high as $10,000, Pollitz said.
For patients with expensive health care needs, finding new coverage is urgent. Case said individuals making the transition from high-risk pools into the health insurance exchanges should take care not to simply choose the cheapest option available to them. Confirming that their current medical providers are participating in any new insurer's network is especially crucial, as is checking whether the plan covers costly brand-name prescription drugs patients may use.
"If you're in the middle of chemotherapy, even if you can move to a cheaper network, if your physician, your oncologist is not in the network, you're not going to move," Case said.
While HealthCare.gov and the exchanges in states like Oregon and Vermont continue to face problems, high-risk pool patients with major medical needs shouldn't wait and should start shopping from insurer to insurer, Case said.
Duffy, who lives in Foster City, Calif., outside San Francisco, made sure her doctors participated in the health plans she considered. Her home state operates its own health insurance exchange, Covered California, so she's been able to research her options.
The Pre-Existing Condition Insurance Plan costs Duffy, who owns a food-service consulting business, $505 a month. It carries a $2,000 deductible and requires her to pay 30 percent of the cost of doctor visits.
On Covered California, Duffy plans to buy a "gold" level plan -- the second most generous category on the exchanges -- from Blue Shield of California that will cost $537 monthly, including tax credits she will receive. The plan has no deductible and a flat $30 fee for doctor visits, though copayments for her medications will go up.
Even though she's looking forward to enrolling in Medicare next August and no longer having to fret about health insurance, and despite her frustration at having to switch plans, Duffy appreciates the coverage she's had since 2010 and the availability of insurance next year. (HuffPost has followed Duffy's quest for affordable health insurance since 2009, when she spoke out about her experience at a town hall meeting on health care reform.) She was uninsured before the federal plan launched in 2010.
"I'm deeply grateful," she said. "Every time I see some senator or some idiot talk about how this is the worst disaster to happen to Americans, I think about writing them a letter."
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