Health Care Reform (8): Temporary High Risk Pools

This is the eighth in an ongoing series of posts examining the Affordable Care Act, including previous posts on health insurance exchanges and tax credits for small businesses.  You can also visit the health care reform page on our website for more resources and information.  If you have thoughts on health care reform, we encourage you to comment below or contribute a guest blog.

Before the passage of federal health care reform, people with serious preexisting conditions were increasingly being pushed to the margins of the health care system.  Many of those with chronic illnesses, like diabetes, or life-threatening diagnosis, like cancer, were vulnerable to not only the symptoms of their medical conditions, but to the financial stress of mounting bills and expensive special treatments.   They faced lifetime claims limits, the possibility of being dropped by their carrier, or being perpetually uninsured because of exorbitant premiums or outright denial of coverage.  A central principle behind the push for health care reform and the resultant consumer protections in the Affordable Care Act (ACA) was that these most vulnerable consumers should not be locked out of the private insurance market.

Some of the first components of the ACA to become law were regulatory changes designed to protect high-risk consumers.  As of 2010, children can no longer be denied coverage because of a preexisting condition, insurance companies can no longer arbitrarily rescind coverage because you get sick, and there are no lifetime limits on insurance coverage.  High-risk patients were offered another form of relief by the ACA in the form of state-based “Pre-Existing Condition Insurance Plans,” which the Sooner State has dubbed the “Oklahoma Temporary High Risk Pool (OTHRP).”  As we blogged last year just before enrollment began, insurance offered through the high risk pool is specifically for individuals who have been locked out of the commercial insurance market because of pre-existing conditions.

Oklahoma residents who have a pre-existing medical condition and have been uninsured for at least six months are encouraged to apply.  According to OTHRP executive director, Tanya Case, the program has reached only about 1/3 of its enrollment capacity.  As of September 1st, 479 members are being covered by the high-risk pool, but the plan has room for hundreds more uninsured Oklahomans.  Benefits are administered by Blue Cross and Blue Shield of Oklahoma and the plan operates much like any other commercial insurance plan, except the premiums are subsidized by a $60 million dollar government allocation, so the cost to the consumer is less.  Premiums are priced at 100 percent of the commercial market rates the consumer would pay if they were not high-risk.

The plan has been a godsend to hundreds of Oklahoma residents who, in some cases, have spent a lifetime struggling to secure affordable care.  A recent article in the Oklahoman profiled three high-risk pool members, including Teresa Simpson:

Before Simpson was accepted and had a right hip replacement in November, she for years suffered excruciating pain.  Her health problems started in high school when she broke a hip and pelvis in a car wreck and spent eight weeks in the hospital; six in traction. She finally had a successful hip replacement in 1987, but it started to fail three years ago.  “I absolutely didn’t know what I was going to do,” said Simpson, a homemaker who had been uninsured since 1996 when her husband started his own carpentry/handyman business. “I couldn’t do anything where my feet touched the ground. Every time I’d move, I’d cry out.”

Fortunately, the high-risk pool is available to offer temporary assistance to Teresa and others like her across the state.  The program expires in 2013 and was designed as a ‘bridge’ program for the high-risk uninsured while the states designed and implemented their online insurance exchanges.  Beginning in 2014, people with pre-existing conditions can shop for coverage through the online state-run exchanges, competitive insurance marketplaces which we’ve blogged about here.  The ACA requires that all states have an operating exchange for their residents to shop for and purchase coverage by the end of 2013.  The high-risk pools were incorporated into the ACA as a stop-gap measure to temporarily cover the most vulnerable uninsured residents.

In addition to providing long-suffering residents with much-needed care, the $60 million dollar high-risk pool gives a boost to local businesses, including the 3rd party administrator of the plan, BCBS of Oklahoma and MaxCare, the Oklahoma City-based pharmacy benefit manager.  The 23 states that opted to let the federal government run their high risk pools missed out on a chance to boost business; an out-of-state group, the Government Employees Health Association, administers their high-risk insurance coverage.  While the high risk pool only affects a sliver of the state’s population, early indications are that those most ill-served by the existing health insurance system are finding enormous relief in the form of affordable coverage and non-discrimination regulations.

Blue Cross and Blue Shield of Oklahoma (BCBSOK), a division of Health Care Service Corporation administers the plan.  For more details call 1-877-885-3717 or check out www.bcbs.com/ohrp.  Also, you may contact Tanya Case, Executive Director of OTHRP at 1-580-512-1488 or via email at Tanya@othrp.org.