Thursday, April 20, 2017

Pre-existing conditions, high risk pools and what changes in the ACA could do to you and yours!!!!

Man!  I promise you!  There is not ONE SINGLE family in this country who does not have at least one family member with a pre-existing condition....certainly as defined by insurance companies. Grandma and her high blood pressure?  Check!  Uncle Jo and his arthritis?  Check!  Little Nancy who spent a couple days in NICU right after birth?  Check!  Momma's asthma?  Absolutely!  Your melanoma?  Oh, yeah!!!  And to make it worse....if insurance companies/government entities were allowed to group folks in high risk pools as identified by THEM....that is one slippery slope indeed. Cause...that broken leg, that one time you needed a little counseling, those extra 20 pounds  (And NO!  I'm not kidding or being silly!!!) could easily be used to put YOU and YOURS in a high risk pool as an individual with a pre-existing condition!!!

For an explanation of what high risk pools mean and how they could affect us's a little Op Ed from one of the smartest dudes I know:  

Let’s take a look at high risk pools for health insurance. An insurance pool is a way to group all the individuals covered by an insurance plan. They share the benefits and the costs of the insurance. The group can be defined in many ways: by a common employer, gender, place of residence, health status, health history like preexisting conditions, occupation, etc. In the case of high risk pools the grouping is done to choose those who are likely to have the most costly medical needs. Having placed the most costly patients in this high risk pool allows the insurance company to be more competitive in the market place for the remaining larger population. Thus, the high risk in these pools is for the insured. The low risk is for the insurance company. By shifting the cost of the most expensive consumers to those very consumers and government sources, high risk pools leave insurance companies with low risk pools for which they can charge lower premiums and make larger profits. Through placing the consumer in a high risk pool because of a preexisting condition, the insurance company shifts the financial exposure to the consumer. These premiums are much higher, often two or three times higher than those for the low risk pool. The coverage is worse often not covering essential services. The deductibles are very large. There are annual and lifetime caps. There is often a gap of 6-12 months before coverage starts. The networks of providers and services are limited. Drug formularies are restricted. To date, experience with high risk pools has demonstrated their woeful inadequacy. Even when correcting for some of the factors restricting access as in the PCIP(Preexisting Condition Insurance Plan), the high risk pool run by the federal government in order to transition to the ACA, only 1-2% of the estimated 27% of the population with preexisting conditions was covered. The PCIP, as well as the state plans in place before the ACA, all suffered from the same problems: Sequestering sicker consumers removed the market based incentive for discounts based on volume. Lack of comprehensive coverage decreased health maintenance. High premiums and deductibles made the subscriber pool unstable. All in all this resulted in poor coverage at great expense for the government and the individuals.

The basic flaw in utilizing high risk pools is that this approach fails to recognize the buffering effect created when as large a portion of a population as possible is included in the risk pool. The basis of insurance is that while the level of risk for most individuals is low, those who are at high risk changes constantly and rapidly. By sharing risk generally, with low and high risk individuals combined, while recognizing that at any moment one may move from the low to the high risk group and vice versa, the risk for the group as a whole is stabilized. Though the whole population may have a slight rise in premiums no one individual is devastated. Shared risk better protects the group all together. Health insurance is something we all use eventually. The buffering effect is also evident with the inclusion of all ages, all genders, and all diseases into the risk pool. The converse is for each individual to bear their own risk. Using high risk pools is an example of this converse approach. For the reasons stated above this is both financially and socially ineffective. It does not produce the most good for the most people. So, in this instance, insistence on the most inclusive pool is the most financially sound within a socially beneficial context. Looking at the examples in the world where this has been put into practice reveals better care at lower cost for whole populations.

The founding principle for health insurance should be the Three Musketeers’ motto ,"One for All and All for One". The principle behind the Republican Plans is the morally myopic Ann Rand motto, "All for Me and Me for Me". A principle that hasn’t worked for the common good and never will.                                             ~ Brent S Morris, MD

Folks, we can be completely, totally well....eating healthy food, running, working and paying taxes one minute, but despite all that, be hit by a Mac truck (or melanoma) the next!!!  Still, if like me, you have good care, a little luck, and some determination, you can rejoin the healthy.  I have always paid my taxes...when sick or well.  I have never be "given " insurance...I bought my own...albeit through the ACA...since before its implementation, I had a pre-existing condition!!!  Folks may have times when they need our help!  However, if we give that assistance, through our generosity of spirit and inclusive insurance pools - many, many illness and injuries can be successfully treated allowing folks affected to not only live the life we all deserve, but return to the working, tax paying world, to financially uplift us all.  

Thank about it!  (And FYI!!!  Despite what my insurance company has had to pay due to my melanoma....they STILL made money on me!!  Yep!  I did the math!!!)  - c

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