Health coverage can be battle of attrition for sick
Insurers can no longer reject customers with expensive medical conditions thanks to the health care overhaul. But consumer advocates warn that companies are still using wiggle room to discourage the sickest — and costliest — patients from enrolling.
Some insurers are excluding well-known cancer centers from the list of providers they cover under a plan; requiring patients to make large, initial payments for HIV medications; or delaying participation in public insurance exchanges created by the overhaul.
Advocates and industry insiders say these practices may dissuade the neediest from signing up and make it likelier that the customers these insurers do serve will be healthier — and less expensive.
“It’s the same insurance companies that are up to the same strategies: Take in as much premium as possible and pay out as little as possible,” said Jerry Flanagan, an attorney with the advocacy group Consumer Watchdog.
Insurers acknowledge that people may see changes in coverage, driven in part by how the overhaul affects insurance. But they say prudent business practices, not discrimination against the sick, are key factors behind some of the trends that have raised concerns.
They point out that if customers find a plan they don’t like, they generally have plenty of additional options to choose from both on and off the exchanges.
They also note that the overhaul takes several steps to discourage them from avoiding costly patients. It prevents insurers from marketing or designing a plan that would discourage someone from applying based on their health.
It also calls for insurers to chip into a pool that compensates competitors who wind up with a more expensive patient population. That lowers their incentive for discouraging the sick from enrolling.
“Health plans now guarantee coverage for individuals and families regardless of health status,” said Clare Krusing, a spokeswoman for the trade association America’s Health Insurance Plans, or AHIP.
There are three major ways insurers still might steer sick or expensive patients away from their coverage:
■ FORM NARROW NETWORKS
Insurers can lower their chances for covering patients with expensive medical conditions like cancer and autism simply by limiting the number of doctors and hospitals in a coverage network. That would send those patients searching for coverage elsewhere because they don’t want to pay expensive, out-of-network rates.
Narrow insurer networks might include only 30 percent or less of a market’s hospitals, as opposed to 70 percent or more for a broader network, according to the consulting firm McKinsey & Co.
These narrow networks have grown more common in recent years, especially in coverage sold on new public health insurance exchanges created by the overhaul.
An Associated Press survey of the nation’s top cancer centers this spring found that patients covered under the health care law could encounter barriers to access in many cases. For instance, MD Anderson Cancer Center said it is included in the networks of less than half of the plans sold on the Houston area’s public insurance exchange.
Aside from excluding patients, narrow networks also can help insurers form a healthy customer base by lowering the cost of coverage.
spokesman said regulators plan to increase their
■ CAUSE PRESCRIPTION STICKER SHOCK
Some plans are requiring patients to initially pay 30 percent or more of the bill for drugs that can cost several thousand dollars a month. HIV drugs and multiple sclerosis medications are among them.
The overhaul caps the annual amounts patients are required to pay for these so-called out-of-pocket expenses. Still, some say the higher cost-sharing requirements can steer patients that need these medications away from enrolling.
“It’s another way to send a message to sicker patients that says, ‘If you’re taking these medications, we’d rather not sell insurance to you,’ ” Flanagan said.
■ ENTER MARKETS CAUTIOUSLY
Another way insurers might land a healthier population is by playing the waiting game.
The nation’s largest health insurer, UnitedHealth Group Inc., will dive into the overhaul’s public insurance exchanges with plans to sell 2015 individual coverage in 24 exchanges. That’s up from only four in 2014.
These exchanges debuted last fall and offer shoppers a chance to compare and buy policies, often with help from an income-based tax credit.
UnitedHealth’s delayed growth could be a savvy way to avoid some of the sickest patients who likely rushed to sign up for insurance in the initial year of the exchanges, said Laszewski, the industry consultant.
That could free UnitedHealth to enter markets and sign up healthier patients after other insurers, most likely nonprofits with deep community roots, have “taken the bullet” the first year, he said.
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