The new health reform law is what I like to call an “over-the-line proposition” because undoubtedly, someone is going to be left out.  What passed the Congress will not bring universal health coverage to America; nor does it assure that everyone is entitled to health care as a matter of right.  It simply adds more people to the current system by giving them subsidies to buy insurance they couldn’t otherwise afford.  In such a system, there will always be people over the line—they won’t qualify for this subsidy or that program either because the government limits its spending on them, or it wants to encourage people to use private insurance to keep those markets strong.

Which brings me to the problem of the new high-risk pools states are supposed to set up to help really sick people who have no options before the law becomes fully effective in 2014. Think of it like your state’s high-risk pool for bad drivers.  Thirty-five states already offer high-risk pools where the coverage may cost twice as much as a policy in the private market available to people who are not sick.  The new pools will operate side-by-side pools already existing but with the government throwing in $5 billion spread around to all the states. The idea is that the extra government funds will make the premiums cheaper in the newer pools.

So here’s the “over-the-line” problem.  The $5 billion is not enough to cover all those needing help, and states are likely to let some join the pools and not others by imposing eligibility requirements.  Will people have to be citizens?  How long must you have had a preexisting condition?  Will the application process be designed to discourage people from applying?  (We know other government programs do that.)

Here’s another catch:  To qualify for the new risk pool coverage, you cannot have had other health insurance for the previous six months.  What an irony!  The very people who are really in need of coverage are disqualified if, for example, they already have coverage even if it is so pricey they can barely afford it.  If you currently get coverage in your state’s older high-risk pool with its sky-high premiums, you’re out of luck and can’t switch to what may be cheaper coverage.  In Texas, for instance, premiums in the new risk pool will cost about half as much as the state’s older risk pool.  So much for comparison shopping!

Then, too, people will be over-the-line if they can’t even afford the premiums even in the new pool.  An older person applying for coverage in one of the new pools will pay four times more than a younger person.  And their out-of-pocket costs will be limited to about $6000 ($12,000 for a family).   Those costs still may be burdensome.  “The unintended consequence of this legislation is we’re going to effectively penalize the people who have been doing the sacrificing all along,” says Oklahoma insurance commissioner Kim Holland.

Still, if you think you qualify for coverage which begins July 1 – and can afford it – check out these websites for more information:  www.naschip.org/states_pools.htm and www.hhs.gov/ociio .  One more thing.  Prepared Patient Forum would like you to be our eyes and ears as these new and somewhat controversial risk pools head toward implementation.  Since there are going to be huge differences among states, we’d like you to tell us what requirements your states are imposing and tell us how much the coverage will cost.  How is this affecting your family budget?  What services are covered and which ones excluded?  We look forward to your comments.