Health & Fitness

A healthcare risk he hopes he can afford

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When it comes to medicine, I usually do as I'm told.

Take a pill? Sure. Blood test? Absolutely. Surgery? If you think so, Doc.

But I've been acting against medical advice since January, and I'll keep on ignoring it until July. Let me explain.

Last January, I canceled my very expensive individual health insurance coverage through California's state-run high-risk plan and became insurance-free. That means that if I get a cancer diagnosis tomorrow, I'll end up with huge medical bills.

I did this because I want to take advantage of the federal government's efforts to help people like me who have preexisting conditions and no access to a group plan, and this is the only way to become eligible.

Those two words — preexisting condition — explain why I find myself in this circumstance.

Back in 1996, when I was 27, my heart started to beat funny. The diagnosis was lone atrial fibrillation, a kind of irregular heartbeat that appeared for no apparent reason and, in my case, couldn't be fixed. Even getting "cardioverted" didn't help.

A daily beta blocker keeps my heart from pumping too fast, and my risk of any complications is low. Even so, no one will insure me on the individual market.

And since I'm single and self-employed as a freelance writer, I don't have access to guaranteed group coverage, except for a plan for artists and writers that would cost me at least $31,226 a year.

That's why, for the last few years, I have made do with the state's high-risk insurance plan. California, where I live, is one of 35 states that offer health insurance to people with preexisting conditions who otherwise wouldn't be able to get individual coverage.

But for me, access to California's high-risk plan is expensive — the preferred-provider plan would cost me $748 a month this year, close to $9,000 a year — and the coverage is thin. The annual spending limit is just $75,000, hardly enough to cover a major health crisis. And the lifetime benefit limit is a paltry $750,000.

As a result of the 2010 federal health coverage overhaul, I now have another possibility: The federal high-risk plan would cost me just $265 a month ($3,180 a year) and offers unlimited annual and lifetime benefits.

That sounds like a great deal cost-wise, and the lack of coverage limits is much better for me in the long run if I get diagnosed with an expensive disease. But there's a rub: I'm not eligible for the federal plan unless I go six months without any coverage at all.

So that's just what I decided to do. To me, the prospect of affordable and unlimited coverage is worth the risk of going without coverage for the allotted time.

"You're responding in an understandable way," said Harold Pollack, a University of Chicago professor who studies healthcare. "Any program that requires people to be actively uninsured creates a very paradoxical and painful set of incentives and encourages people to do what you're doing."

But I'm taking a major risk by going without insurance for so long. This would be the absolute wrong time to get hit by the proverbial bus. Or, as happened a few weeks ago, hear a dermatologist ask, "Have you had that looked at?" while I lounge at a hotel pool. (Don't worry. I'd previously had it looked at, and it's nothing to worry about.)

My decision to go coverage-free did not go over well up in Sacramento when I mentioned it to staffers at the California Managed Risk Medical Insurance Board, which oversees the state and federal high-risk plans here.

A spokeswoman told me that the agency wouldn't cooperate with me on this story if I planned to embolden other people to make the same decision. Janette Casillas, the agency's executive director, put it this way: Going without insurance in order to get insurance "is not something that we would encourage."

The federal government could change everything by getting rid of that six-months-without-coverage rule. But if it did, it would need to find another way to limit coverage for high-risk patients so it doesn't cost more than the budgeted amount, Pollack said.

"They'd have to have some other rationing requirement that would also create problems, since it's such a small program for such a huge need," he said. "Almost every deficit of this program comes down to the fact that Congress has not appropriated enough money to meet the need that is there."

Even if I do land in the federal high-risk plan as of July 1 — if space is available — it's not a long-term fix for me or anyone else. The good news, for me at least: In 2014, the federal health law is scheduled to take full effect, including provisions that protect consumers who have preexisting conditions from being denied coverage. The high-risk pool coverage won't be needed anymore.

But what if the Supreme Court nixes the healthcare law? What happens next? Is it possible that funding for the federal program might disappear before 2014?

Sandy Praeger, commissioner of the Kansas Insurance Department, thinks funding for the federal high-risk pools will vanish if the Supreme Court entirely overturns healthcare reform.

In Kansas, she said, the federal high-risk plan serves about 400 people, some of whom are quite ill. But it's pricey. For each $1 in premiums in Kansas, she said, the program pays out $10 in claims.

For now, state insurance officials nationwide are making contingency plans for what they'll do if the federal high-risk plan disappears, said Amie Goldman, who oversees Wisconsin's high-risk plans.

In Wisconsin, she said, officials have already decided that residents who lose the federal coverage will be able to join the state high-risk plan and retain continuous coverage. "We wanted to be ready because we know people are going to call immediately and be very concerned. We have a lot of people who are relying on this coverage for sometimes-lifesaving treatments. We have nine people in our [federal plan] who have been approved and are on waiting lists for transplants."

Ultimately, she said, the future of the high-risk programs in Wisconsin will depend on the Supreme Court opinion and, if necessary, on legal analysis regarding the breaking of insurance-related contracts that are already in place.

Here in California, my health insurance future is uncertain. If the health law is overturned, I may have no choice but to go back to paying about $9,000 a year for California's paltry high-risk plan.

There's one tiny bit of good news. A state legislator is pushing a bill to eliminate the annual and lifetime benefit caps from California's high-risk plan, which is known by the adorable term "Mr. Mip." (That stands for MRMIP, or Major Risk Medical Insurance Program). The bill's chances may not be adorable. It would require more state spending, after all.

For now, I'm just hoping nothing goes wrong until I get insurance again.

Dotinga writes for Kaiser Health News, an editorially independent news service and a program of the Kaiser Family Foundation, a nonpartisan healthcare policy research organization. Neither Kaiser Health News nor the foundation is affiliated with Kaiser Permanente.

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