High-risk pools can provide immediate help, but how much?

Pat Wallick hasn’t had insurance since 2002. He has herniated discs and high cholesterol, which disqualify him for most plans.

JIM DAMASKE | Times

Pat Wallick hasn’t had insurance since 2002. He has herniated discs and high cholesterol, which disqualify him for most plans.

Pat Wallick hasn't had health insurance since 2002. The Port Richey man has a herniated disc and high cholesterol, conditions that disqualify him from nearly every individual health plan on the market.

These days, Wallick, 55, pays for as much medical care as his $26,000 annual disability pension from Burlington Northern Santa Fe Railway allows. But it's not enough.

"Doctors are telling me that I need another MRI and other tests for my back, and a stress test for chest pains I've been having," said Wallick. "I can't afford that."

But with the signing of the health reform bill this week, Wallick may soon be able to get insurance through a federal high-risk pool, aimed at people denied coverage because of pre-existing medical conditions. The bill directs the U.S. Health and Human Services Secretary Kathleen Sebelius to create the pool within 90 days.

Supporters say the pool will quickly help reduce the number of uninsured Americans, estimated at 47 million. U.S. Rep. Kathy Castor, D-Tampa, called it "a dramatic step to making health care coverage affordable and available."

But insurance experts say that without adequate funding and cost-containment measures, the federal high-risk pool could face the same financial challenges as Florida's high-risk pool, which has been closed to new enrollees for nearly 20 years.

• • •

The high-risk pool will be among the first health reform provisions to take effect. Though details have not yet been hammered out, it's expected that the pool will function much like high-risk pools in more than 30 states, including Florida.

The bill says the new federal pool is for those who have been uninsured for at least six months and have a pre-existing medical condition. Premiums in state pools are usually higher than the average rates for individual insurance plans, though the federal bill says limits will be set on how much can be charged. The bill also includes $5 billion in federal funds to help pay for the program.

The federal high-risk pool is temporary. It will remain in effect until 2014, when other provisions of the reform bill, such as mandatory coverage and the creation of health insurance exchanges, kick in.

"High-risk pools are a good idea," said Wayne Sakamoto, president of Health Insurance Interactive, a Naples insurance agency.

For one, the pools provide coverage for people who need it and can afford it, he said. But the pools also take away what he called "risk to the marketplace." People who are uninsured often get their care in hospital emergency rooms at a higher cost, which ultimately drives up costs for everyone who is insured through higher premiums.

Lori Parham, state director of AARP Florida, also praised the high-risk pool, because it will help her members who aren't old enough for Medicare. Among the largest numbers of people who can't get insurance because of pre-existing conditions are those ages 50 to 64.

Wallick is among them. He said he had heard about the state's high-risk pool but was disappointed to learn that it no longer accepted enrollees.

He said he would "absolutely" consider joining the new high-risk pool. "I was really nervous. I didn't think the bill would pass," he said.

• • •

But high-risk pools are expensive. People with multiple medical conditions need a lot of health care, something that Florida knows all too well.

The state created its own high-risk pool in 1982, and at its peak it had more than 7,000 members. But in 1991, with the program losing tens of millions of dollars, the state stopped accepting new enrollees.

Now, nearly 20 years later and with fewer than 300 people left in the pool, it still is closed.

Randy Kammer, vice president of regulatory affairs and public policy for Blue Cross Blue Shield of Florida, said one problem with Florida's pool was that in its early years, very little was done to control costs.

"There was tremendous utilization, and people were having high-cost procedures," Kammer said, recalling one case where a patient went out of state for care and came back with a $300,000 bill — which the pool paid.

The state increased premiums to as high as 250 percent of the average rate, and it brought in a new insurer — Blue Cross Blue Shield of Florida — to administer the high-risk pool and impose spending restraints. But those steps were not enough to offset the mounting losses, and the state stopped new enrollments.

To this day, assessments are collected from all licensed health insurers in the state to pay for the high risk pool.

"That's still happening today for the 200-300" who are left in the pool, Kammer said.

• • •

Castor said having a larger, national pool will make the new program far different than Florida's, as will the $5-billion appropriation.

But some wonder how far that will go.

"It's a lot of money, but is it enough money to cover the uninsurables in the U.S.?" Sakamoto asked.

Kammer was more certain: "They are going to find that the $5 billion will not hold them over until 2014."

She hopes that the federal high-risk pool can manage costs, by bringing in people who understand how to manage the treatment of chronic diseases, such as Wallick's back problems and high cholesterol.

"That would be a critical piece," she said.

Richard Martin can be reached at rmartin@sptimes.com or (727) 893-8330.

High-risk pools can provide immediate help, but how much? 03/24/10 [Last modified: Friday, March 26, 2010 9:53pm]

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