Even with health insurance, Texans in high-risk pool struggle : Mary Ann Roser
By: Health Insurance
Submitted: 2009-08-24 12:49:11 | Word Count: 1172
A medical condition and a divorce left Austin musician Chris Bennett searching for health insurance in 2001. He tried to buy an individual policy, but an esophageal disorder made him a marked man to insurers.
"I spent a long time on the phone," said Bennett, 57, a drummer and percussion teacher. "But everyone said no."
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Then, he found the Texas Health Insurance Risk Pool in 2002. It seemed like a godsend, especially after several bouts of illness. But he soon discovered that even state-run pools are not a guaranteed safety net. Escalating premiums and mounting medical bills eventually forced Bennett into bankruptcy.
So, even though he has health insurance, Bennett says he hopes the health care overhaul bill being debated in Washington will provide some relief for the insured as well as the uninsured.
"The very system meant to 'insure' an individual's health causes a financial crisis," Bennett said of the current health care system. "Last year's been the worst year of my life, and that's just me. What about the other millions of people in this country?"
Bennett is among 27,000 Texans enrolled in the Health Insurance Risk Pool, administered by Blue Cross Blue Shield of Texas and paid for by premiums and fees levied on insurers doing business in Texas.
Thirty-five states have such plans, aimed at helping middle-class Americans who find themselves priced out of the market or excluded because of a medical condition, according to the National Association of State Comprehensive Health Insurance Plans.
No one knows yet whether high-risk pools would be rendered unnecessary or expanded to cover more people if Congress enacts health care reform.
The bill put forward this summer by three U.S. House committees would require all Americans to have health insurance, and it specifically states that high-risk pools would be one way to fulfill that requirement. But the legislation also would prohibit insurers from denying coverage to anyone because of a pre-existing condition, so ultimately, such pools might not be necessary.
Officials with state high-risk pools say they are watching the legislation closely but that it's too early to tell how the proposed changes mightaffect the pools or their members.
And change, if it comes, is at least several years away. In the meantime, people like Bennett are grateful to have insurance, even though they struggle to keep it.
Christian Rodriguez, a 22-year-old college student in Spring who has hemophilia, a blood-clotting disorder, expects to reach the $2 million lifetime maximum in benefits offered by the Texas pool in December.
He is grateful that it covers his expensive clotting treatment but said his hope now is to find a job with good insurance. He added that private organizations help him pay his $432 a month premiums to the pool.
Bennett said he was squeezed by premiums of more than $700 a month and co-pays totaling $40,000, which forced him to file for bankruptcy and resulted in the loss of his company, which made replicas of drumsticks used by famous jazz musicians and shipped them to buyers worldwide.
Yet the risk pool coverage gave him access to specialists and medical care that might otherwise have been denied him, said his longtime primary care physician, Dr. Donald Counts of Austin. Bennett suffered a back fracture in 2006, which was traced to osteoporosis and an inability to absorb vitamin D. That finding prompted a battery of tests. Ultimately, he was diagnosed with a rare form of leukemia that required treatment at the University of Texas M.D. Anderson Cancer Center in Houston.
Steven Browning, executive director of the Texas pool, said the program has saved others from bankruptcy.
Cyndi Payne of Montgomery is one of them. She said that if the pool did not cover her daughter's multiple medical problems, she and her husband "would be probably bankrupt and probably stressed to the point of divorce."
The high-risk pool also helps keep the cost of insurance lower for commercially insured people because they keep some of the costliest, highest-risk people out of those plans, said Lanny Craft, chairman of the national association and executive director of the Mississippi high-risk pool. "They keep insurance rates very reasonable."
"High-risk pools have provided a very valuable service to states," Craft said.
But for those in the pool, which is required by state law to charge double the market rate, high premiums are an increasing problem.
The Texas risk pool's 2008 annual report said customer satisfaction was high among members who canceled the coverage (some got jobs with employer coverage, others became old enough for Medicare, others canceledfor different reasons) and that "the vast majority of negative comments related to high premium rates."
Premiums range from $157 a month for a child up to age 19 to $1,870 a month for a 64-year-old male smoker, Browning said. The average premium is $615 a month, not counting co-pays and other out-of-pocket costs.
Bennett said he paid about $400 a month when he signed up in 2002 and is paying $702 now. He recently got a letter informing him of the latest price increase.
"I'm afraid to open it," he said.
Twenty-five percent of the 8,400 people who left the pool last year were terminated for not paying premiums, according to the annual report. It's likely some significant portion could not afford them, Browning said.
This spring, the Texas Legislature sought to help people in the pool pay their premiums. Lawmakers passed House Bill 2064, which would provide premium discounts of 50 percent for people whose household income is below 200 percent of the federal poverty level and 30 percent for people whose household income is between 200 percent and 300 percent of the poverty level, effective in 2011.
The legislation will be funded by fines the state levies against insurance companies for paying claims late to doctors and other medical providers.
Data show that Texas pool enrollment dipped slightly last year, a possible effect of the economic recession. In fact, more people left the pool last year than joined.
Bennett said that while he wonders how long he can pay the premiums, he doubts he will ever "graduate" from the pool, as long as it exists. "I don't really see a way out," he said.
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