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Call me crazy. I'm a few months from losing my health insurance coverage – the COBRA plan you can buy after you leave a job that initially provided the benefit. So I figured I should start planning now to find an individual policy to replace my current plan before I lose it. This shouldn't be too difficult, right?
After all, the federal Affordable Care Act – colloquially known as "Obamacare" – was signed into law two years ago. Its mandate that all American citizens obtain coverage of some sort, coupled with a prohibition on insurers denying applicants because of pre-existing health conditions, takes effect in less than two years, assuming the U.S. Supreme Court doesn't strike it down after hearings this week.
It couldn't be all that tough, I thought to myself, to find an affordable health plan.
I was wrong.
Advocates of President Barack Obama's health reform say I am a case study in how untold numbers of Americans have been caught in a no man's land waiting for the new federal law to take full effect.
I am a healthy 51-year-old freelance writer. I've never had a major illness or disease (knock on wood). The only broken bone I've ever suffered was a fractured jaw, and that was almost three decades ago. I have minor, not-so-unusual conditions for an African American male of my age – borderline high cholesterol and high blood pressure, which have been controlled by one medication each for years, and a hormonal issue for which I also take medication. I'm not overweight. I don't smoke, and my drinking habits are somewhere between light and moderate.
But three insurance companies – Blue Shield of California, Kaiser Permanente and Aetna – all refused to cover me, at any price. Anthem Blue Cross said yes – but only if I accepted a plan that would cost more than three times as much as the plan for which I applied, or $1,350 a month. The justification cited by all four insurers: pre-existing conditions.
This is the state of American health insurance, California-style, circa 2012.
To understand why this is so, I consulted one of the state's leading experts on insurance, UCLA professor Gerald Kominski, director of the Center for Health Policy Research. My predicament, he said, was one of the unfortunate consequences of the long lag between the approval of the federal health reform and its implementation.
"You're in limbo," Kominski said, capturing my condition precisely. "You are a classic case study as to why this legislation is so important and this law is so important … because you cannot find affordable health insurance despite the fact that you are reasonably healthy."
My situation is not rare, reports Michael Russo, who follows health insurance issues for the California Public Interest Research Group, or CalPIRG. "I don't think it's really uncommon at all, sadly," he said. Large numbers of individual applicants are denied or steered to more expensive plans, he said. "It's a ridiculously high percentage."
I thought it might be instructive to peer behind the curtains of the four health insurers to which I applied to see how they concluded I was just too much of a risk. Alas, these wizards said nope, no, no way. They did not want to share any insights into the application process, or at least what happened to my application.
"I've been told we generally decline these types of requests," Darrell Ng, a Blue Cross spokesman, stated in an email.
Aetna's spokeswoman, Anjie Coplin, had me sign a release so she could discuss my situation, then told me what was already obvious: I was denied because of my pre-existing conditions. She never addressed my request for a further explanation of what made my ailments actuarially scary.
Angenette Lau of Blue Shield emailed, "We do not comment on any specific application." Am I to understand that Blue Shield will not comment to me about its denial of my own application? "Correct," she replied.
Kaiser's policy was similar: There'd be no discussion of my application's denial, said spokesman Won Ha.
But here's what I can tell you:
On all four applications, I stated what I know of my medical condition: slightly elevated blood pressure and cholesterol, as well as lower than normal testosterone and infrequent but minor ear infections. I also mentioned that in 2009 and 2010, I saw a therapist every two weeks or so for counseling for mild depression tied to a divorce and the death of my parents, and that there was no medication or hospitalization involved. And I noted my long-simmering but minor athlete's foot that was resolved last year through a 90-day course of medication, with no side effects or subsequent treatment.
Representatives of Aetna and Blue Cross called with further questions, which I answered.
In its denial letter, Aetna listed blood pressure, cholesterol, ear infections and low testosterone as its reasons. It also cited "parathyroid disorder," an ailment I've never had and which I did not list on my application. In fact, the questionnaire asked whether I suffered in the last five years from ailments such as diabetes, thyroid disorders or lupus. I answered no. But since Aetna isn't talking, I guess I'll never know how it divined that I indeed do suffer from parathyroid disorder.
Kaiser cited the cholesterol, blood pressure, testosterone and ear infections, but also threw in the athlete's foot and my "depression."
Blue Shield pointed to the blood pressure, cholesterol, and testosterone issues, and said its "other concerns are history of depression treated with counseling."
Blue Cross apparently didn't care about my alleged "history of depression." But it did cite the blood pressure, cholesterol and testosterone ailments, and "erectile dysfunction – treated with Cialis and Viagra."
During the phone interview with a Blue Cross representative, I was asked if I have an undescended testicle or a malignancy in or near one; have used a penile implant; or plan testicular surgery, infertility treatments or related procedures. I answered no to all of those queries. What was the "underlying cause" of the erectile dysfunction? According to the specialist who first diagnosed the condition eight or nine years ago, I replied, the cause was low testosterone. I also told the interviewer that the doctor prescribed both a daily testosterone supplement and the use of Cialis or Viagra. My subsequent physicians have continued that treatment, I said.
But that was too much for Blue Cross. I'd love to ask why it was so concerned about the sex-related aspects of my medical history, but as Ng said, the company does not discuss the reasons behind its inquiries.
Since the insurers were no help, I posed some general questions to Patrick Johnston, a former Democratic state legislator and currently the director of the California Association of Health Plans, a coalition of 40 health insurers. I asked him to explain the insurance industry business model that leads companies to refuse to sell their product to anyone they think might actually need it some day.
He helpfully talked about how insurance actuaries usually conclude that younger adults are cheaper to insure than older ones, and how they find it difficult to assess risk on individual applicants.
"When you're dealing with an individual … the actuary has no one else to pool (him or her) with except other people in that age group living in that area, and then has to apply the factor of how likely is this person going to need health care services," Johnston said. "So the (application) questionnaire that indicates health status is a way to standardize that risk."
Of course, he and others noted, the world will change on Jan. 1, 2014, when the federal health reform's main components – the prohibition on pre-existing conditions being used to deny applicants or to charge higher rates, and the requirement that everyone obtain insurance – take effect. Individual consumers then will be able to seek coverage directly from insurers or through the state's Health Benefit Exchange, an online bazaar of sorts that is intended to ease the chore of comparing and buying policies. Sliding-scale subsidies will help low- and moderate-income buyers afford the coverage.
"Could it have been done sooner? Yeah," said Anthony Wright, executive director of Health Access California, a health care consumer advocacy coalition. "But there actually was a need to have some time built in, to both put the infrastructure in place and also to give time for the market to transition because we are going from the wild, wild West here in California to hopefully a transparent, consumer-friendly market."
Still, 2014 is 21 months away, and the end of my COBRA coverage this August is fast approaching. Yes, there is the state's Pre-Existing Condition Insurance Plan, its Major Risk Medical Insurance Program, or provisions of the federal Health Insurance Portability and Accountability Act. But each has its own significant drawbacks, such as requiring an applicant to go without insurance for six months, a temporary ban on coverage of pre-existing conditions, or haziness about the scope and cost of coverage.
So for now I sit and wait, facing the prospect of going without insurance until Obamacare kicks in – or paying more than $16,000 a year for the only policy one of these companies will sell me. Neither of those is a very pleasant option.
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