New Coverage Coming for Pre-Existing Conditions
Multiple sclerosis patient Marc Fladell and millions like him hope they will benefit when the first major piece of national health reform begins this month.

Fladell, 47, needs lots of treatment in his 18-year battle with multiple sclerosis, but he lost his job and then his extended health insurance ran out two years ago. No insurer will touch him because of his illness, leaving him to pay his own medical bills of $300-plus per month.

The MS lets the Pompano Beach attorney work only part-time, so he often skimps on or skips medical care. He stopped going to the doctor for pain in his limbs or torso; he just ices down and takes the pain. If he gets the flu or other symptoms, he may see a nurse at a drugstore. His costly MS drug comes free from a manufacturer charity program, but when he needs other drugs, he often goes without them.

Now Fladell is warily hopeful because the government on June 23 will start to roll out "high-risk pools" in each state offering guaranteed coverage to people with pre-existing conditions.

"I would love to have insurance. I would pay whatever I have to, although I can't afford too much," Fladell said. "I didn't ask for MS. MS chose me. I just want the same ability to get insurance as everyone else has."

Yet experts say the $5 billion program will cover only a fraction of those who need it, and the coverage will be expensive.

Moreover, if Florida's experience is any indicator, the cost could be prohibitive: The state's experiment with a high-risk pool in 1982 collapsed in less than a decade because of spiraling expenses.

Covering the uninsured was among the top priorities of the health reform law passed by President Obama and Congress, especially for those who have been refused coverage or charged huge premiums because they have cancer, heart disease or even conditions such as asthma.

The high-risk pool program is a temporary fix, lasting until the main part of health reform launches in 2014 with insurance exchanges that will offer guaranteed coverage for all and subsidies for many.

The temporary pools will be open to all those with pre-existing conditions who have been uninsured for at least six months. Insurers or public agencies selling policies in the pools cannot charge more than for a typical individual policy on the open market. That may cut premiums by half or more compared with policies available now, although the prices will likely vary widely.

The pools should be most helpful to people age 55 to 64 who are more likely to be ill and are too young for Medicare, said Sara R. Collins, of the non-profit health policy group the Commonwealth Fund.

The pools end "this costly and unfair practice that allowed insurance companies to cherry-pick the healthiest beneficiaries while denying coverage" or charging chronically ill people higher premiums, House Speaker Nancy Pelosi said this month.

But the coverage will not be ideal. The average family health policy in Florida is $1,200 a month. The pools need cover only 65 percent of medical costs. Patients will have to cover co-pays, although no more than $5,950 a year for an individual, $11,900 for a family under the new law.

Nor will it cover everyone. Congress set aside $5 billion to run the pools through 2013, of which $351 million goes to Florida. Experts on all sides agree that's a drop in the bucket compared to the need.

Of the 50 million uninsured Americans, about 7 million have pre-existing conditions and will be eligible for the program. A study for the National Institute for Health Care Reform found that the program will have enough money to cover about 200,000 of them.

In Florida, the program will be able to cover maybe 30,000 of an estimated 500,000 eligible people, said Jerry Ashford, executive director of the Florida Comprehensive Health Association, a tiny high-risk pool set up by the state.

It's still unclear how officials would choose which Floridians will qualify—perhaps by first-come, first-served basis, by lottery, by financial need. But making it fair will be difficult, Ashford said.

"It's going to be sort of a gold rush race to get to the pot of gold," Ashford said.

Barring some other action, the rest will continue as they have been. If the money runs out early, experts said officials will have to find more cash, scale back benefits or drop the number covered.