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The Business of
Health Care Report In large, employer-based HMOs, usually everybody is accepted who signs up. For large PPOs, individuals can be accepted with the exclusion of pre-existing conditions. But in the individual market - where an individual or a family buys direct from an insurer -- options to deny coverage to applicants are broader. With a few exceptions, insurers are free to reject whom they wish or to adjust premiums based on medical history, age, weight, personal habits such as smoking and drinking, or even chronic, minor health problems. Nationwide, an estimated 2 million high risk people are willing to buy insurance but are considered to be medically uninsurable, according to a recent study by PriceWaterhouseCoopers. And their ranks could swell if the economy continues to weaken and unemployment rises. Those losing their jobs may drop from employer-subsidized coverage and have to seek individual coverage, thereby having to meet a higher standard for insurability. By some industry estimates, 20 percent of people who apply for health coverage in the individual market are rejected. A study by the Kaiser Family Foundation put the rejection rate at 35 percent. There's no shortage of ideas, or of disagreement, about how to improve access to individual health insurance. But much of the political debate focuses instead on affordability, overlooking those who are willing to pay but can't get insurance companies to sell to them. The risk of pooling at-risk patients is very high for insurers. But the financial risk to our health care system, which continues to care for these patients, is great as well. Access to insurance - whether group coverage through employers or individual coverage direct to the insurer - remains one of the priorities within our country. If you have comments on health care or suggestions for topics to be addressed on this program, e-mail me at DougHawthorne@TexasHealth.org. Sources: Price WaterhouseCoopers LLP; Kaiser Family Foundation Stay tuned to our weekly Business of Health Care reports here on TexasHealth.org and on News Radio 1080 KRLD. ©
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