HEALTH PLANS/POLICY: And it’s a right, and a left, and another right–I’m not sure he can take any more…

You’d think the LA Times’s Lisa Girion would have had the human decency to stop beating up the health insurance industry. It’s getting close to the time when the referee should step in to save the insurers from further punishment. But oh no, it’s haymakers landing on the chin time after time.

This time she uncovers another little nuance about why the individual insurance market is such a disaster—entire classifications of occupations are automatically disqualified. Good article, go read it.

I’m reminded of two things. One, back in 1991 Mary Ann O’Sullivan then (I think) of Health Access gave a speech in which she described exactly the same thing. She quoted one insurer denying used car salesmen insurance because “you just can’t trust those people!”

Two, I paraglide, and on the paragliding list in a discussion about how to make sure that your health insurance covered paragliding we got a beautifully naive question from a recent immigrant from (I think) Hungary where the national paragliding association groups together and buys health insurance for its members. He suggested that the US national association did the same thing as the Hungarians! Some of us on the list suggested that this might not be the best way to go about finding affordable insurance.


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  1. That may well be true. I’ve seen them even create “evidence” of non-payment of premium ( even though the cashed the checks ), in order to cancel a group they no longer wanted.
    If SBD is not guilty and can prove it, he should be federeally eligible and guarantee issue. If nothing else, he can form a small group on his own by hiring his spouse or a business partner.

  2. Tim, SBD has only been ACCUSED of fraud, not tried and convicted. And the accusation is from an insurance company, not something I would take as truth by any stretch. As usual insurance companies get to be judge and jury while it’s the insured’s responsibility to pay legal fees to bring light to the issue. Why don’t we require insurance companies to prove before conviction and cancellation? Insurance companies are your friend :>)

  3. <<<>>>
    If nothing else, you could form your own business entity, and have a group of two people on the plan. Small groups are guaranteed issue.
    Then again, if you have comitted fraud, that may be an exception.

  4. What exactly is “fraud” in this case? If for any reason you would be Federally Eligible… I don’t think the waiting list applies. Just like Ohio has HIPAA plans with open enrollment and maximum numbers for any given carrier ( that they must take ), if you are federally eligible, that is bypassed.
    If you are guilty of fraud, however, you have created your own mess. What is it that you have alledgedly done to be found guilty of fraud?

  5. Tim, please point me to a Health Insurance I can apply for and be accepted in the State of California.
    It is my understanding that in order to qualify for Medical or Medicare, I must be disabled for two years prior to be accepted.
    The requirements for California’s MRMIP insurance also make me ineligable because my previous insurance company canceled my policy and accused me of fraud. I have filed a lawsuit because of this, but their letter is what I must supply to MRMIP for enrollment.
    This is from the MRMIB quailification requirements.
    You have been involuntarily terminated from health insurance coverage within the previous 12 months for reasons other than nonpayment of premium or fraud. A letter/copy of a letter indicating involuntary termination from a health insurance carrier, health plan, health maintenance organization or employer for reasons other than nonpayment of premium or fraud must be submitted with your complete application.
    From what I have read, there is a 2 year waiting list even if elligable for MRMIP.
    If the MRMIP is not at maximum enrollment and all other eligibility criteria are met, you will be enrolled in the MRMIP on the date that eligibility will occur. If the MRMIP is at maximum enrollment at the time you become eligible, you will be placed on a waiting list. Your place on the waiting list is determined by the date on which your complete application was received, not the date that you became eligible for the MRMIP.
    Pointing me to where I can get Health Insurance would be very helpful to me, so please Tim tell me where I can get this coverage?

  6. I don’t know if I won anything or not, I’m just trying to show that there are other options. Although California’s particular state plan is rather shoddy in terms of lifetime an annual caps in comparison to other state plans, you’d be hard pressed to spend it all on medications and surgeries without being qualified for Medicaid or Medicare.
    No one is being told there is no insurance avaiable for them “no matter the cost”. If you can get individual, good for you. If you can’t, don’t fret… you are just going to have to pay more. If anyone should be doing anything about healthcare at all, it should be making the STATE PLANS more affordable through additional government funding ( say, lottery income for instance; just an example ). This is particularly true for those that would fall into the grey area where the plans are very expensive for them to keep, yet they don’t quite qualify for the other income based options. There is no need to take it out on the individual policies and the carriers that underwrite them. There are other options.

  7. “Also a fair question to ask your doctor.”
    John, not the ice breaker question you want to start a doc visit with when establishing a relationship :>).
    But here is my recent approach to a new doc I visited for a lingering stomack problem last week. It’s been 15 or more years since I needed a GP visit. I had been trying to self fix a constant upset/sour stomack. I did not owe this doc anything and was prepared to walk if he didn’t meet expectations. After I explained my symtoms I said that I don’t condone or believe in doctor based defensive medicine. I was paying cash and said we needed to approach this problem with intelligence and reason. He agreed and as he went through his analysis and recommended blood work I made him justify each test, which only came to 3; liver function (I knew it was not my liver, but hey can’t hurt), white blood cell count (OK), and peptic ulcer anti-body (good one to pick). No scopes in my various body accesses or multiple tests that don’t mean anything. I guess he didn’t have a financial stake in any labs. He gave me 21 day samples of Nexium for which I did research and found that there are cheaper and just as good alternatives. We finally decided on Prilosec OTC for acid control, this would not have happened unless I did reaeach and made him give me an alternative. I am now attempting to get to the root cause of this so that I can get off the acid control pills. Docs do drive the system and as gate keepers need to be kept in check.

  8. But you CAN get helath insurance. Just like care insurance ( I know how much you love that comparison 8^) ) there are options for the otherwise “unsinsurable”. Yes, it costs more, just like high risk auto. But, unlike high risk auto, the plans are pretty nice. I’d even venture to say that the plans are better than many group plans out there and many individual plans. Take a look at this:
    There IS health insurance for the higher risk people. The argument that they won’t take them “no matter what they are willing to pay” doesn’t stand. Here is an option. More exspensive, yes. But what do you expect for a higher risk?

  9. Tim, the difference is that if you can’t get auto insurance, you can take the bus or walk. If you can’t get Health Insurance, you go Bankrupt and/or Die.

  10. SBD,
    You missed one thing. Your DUI driver will NOT be insured by many carriers. Only certain carriers will even LOOK at them, and those that do will make them pay dearly for it. It’s called HIGH RISK INSURANCE. Call around to numerous carriers this afternoon, tell them you have a DUI, and ask if they can insure you. Better yet, tell them you’ve gone without insurance for three months and want back in the game. Good luck.
    Same thing applies for certain health conditions and occupations. There are medications, conditions, health history, occupation, etc. that certain carriers will cross off the list for individual plans. If you were an insurance company offering lower priced individual plans ( low risk ), would you want to add high risk people to your low risk pool voluntarily? No. Why not? Too much risk and expense on the table.
    The key thing here is that individual insurance is something you have to qualify for, period. That’s why the rates are typically so much lower. If a certain carrier has rules you don’t like, go to another carrier. No one’s forcing you to try and buy their plans. Trying to force them all to underwrite the same way is a joke. It won’t happen. Yes it’s about making money, but it’s also about having less expensive insurance for those that are healthy enough to get it. Certain occupations are certainly more prone to higher risks and health problems and/or accidents.
    I agree that it seems unfair, but that’s just how it is. In reality that is the only benefit to small group insurance versus individual plans. They HAVE to take you. They may rate you up as high as they are allowed, but they must take you as a small group.

  11. “Does anybody believe that it’s about healthcare and not profits?”
    Fair point.
    Also a fair question to ask your doctor.

  12. SBD has it nailed. That’s one reason why these mandated health insurance plans will fail, they rely on the same insurance/health delivery system that got us here. They assume more premium payers in essentially the same “free market” system will somehow control costs. It sounds like Bush’s Iraq policy – “stay the course”. Does anybody believe that insurance companies consider patients when they write policies? Does anybody believe that it’s about healthcare and not profits?

  13. I can’t believe that Tim compared this to car insurance. You can get car insurance for your teenage son and even if you have a DUI, you just have to pay more. That is not the case with Individual Health Policies. They are excluding entire class of people and it has nothing to do with their health. They won’t insure these people no matter how much they are willing to pay.
    The real reason why they exclude entire industries is really quite simple. They know which industries cost them the most money because that information is right at their finger tips. Their main business is selling Group Plans. Each Group Plan is tied to a business in a certain industry. Everytime someone gets sick or diagnosed with a certain disease, that information ties right back to the company and that particular industry.
    Rather than use this information for the good of the general public, they use it to make pure profit in the individual market. The individual market is a goldmine for them and they know. It is a profit machine that they are going to fight hard to make sure it does not change one bit.
    They have the disease numbers and that is all that matters. I would bet that either UnitedHealth or Pacificare provides Group insurance for the firefighters and police officers in California. If I worked in one of those industries on this list, I would be very concerned someone was not telling me about my health risk associated with my job.

  14. At least in Ohio, Indiana,and Kentucky, just because you can’t get individual insurance doesn’t mean you can’t get insurance. That’s what the state access and HIPAA plans are for; the higher risk pool.
    Most people don’t hear about them for two reasons:
    1) There’s no comission in it, or very little.
    2) The state has the plan available but doesn’t like the risk.
    The HIPAA plans that are offered by the carriers are excellent plans as well.
    Both are more expensive than individual health plans, but they are often less expensive than many group plans.
    For those with lower incomes, there’s the CHIP programs.
    People have other options available to them, but there is no free lunch.

  15. Tim–that is exactly the problem. The logical conclusion is that no insurance pool can survive because underwriting strips its healthiest people away. But the sick ones are going to get sick and cost money anyway. How you can read this article and not realize that this system doesn’t solve the basic problem of getting people access to needed care is just beyond me.

  16. I don’t really see the problem here. You have to QUALIFY to get individual insurance. That’s why the rates are so much less expensive. Once you are in though, they can’t cancel you as long as you pay the premiums.
    I have a client here who was refused individual because her takes Embrol, at $350 a pop, twice a week. That’s 30k a year. Ironically, we put him in a small group with two employees and he is guarnateed coverage. Now, for a premum of about $450 a month just for himsself, and an out of pocket of $4000 worst case, he is covered. Instead of 30k a year, he spends 10k.
    Although the primary use of Embrol is for Rheumatoid Arthritis, it has a secondary effect of clearing Psoriasis. He has the latter.
    The individual market is less expensive because you have to qualify to get in, and that’s determined by each carrier. It’s just like car insurance in may ways. The carriers give you different prices for different coverage. Some may take you, some may not. Some cars cost more to insure. Some classify groups of people such as teenagers, delivery drivers, etc. as high risk. It’s just simple math.