by John Geyman, M.D.

My last blog discussed how little, if anything, there is to the Republican alternative health care plan as it seeks to defund the Affordable Care Act (ACA). Now, a large group of House conservatives are trotting out one more already failed attempt at “reform”—high-risk pools. They are pushing a bill that would increase government funding for high-risk pools while providing expanded tax breaks for consumers who purchase their own insurance. 

High-risk pools have been tried in many states for years with the hope to increase opportunities for people to get health insurance in the individual market. They have received both state and federal funding. Laudable as this might sound, it hasn’t yet worked. These high-risk pools are plagued by many problems, including limited benefits (e.g. exclusion of maternity care and mental health), high premiums, extended waiting lists, and inadequate funding. (1) At best, high-risk pools are just a drop in the bucket of need. In 2006, for example, California had one of the largest such pools in the country, and still only covered 0.0013 percent of its uninsured population in this way. (2) 

About 35 states had some form of high-risk pools before the ACA was enacted. All states now have Pre-Existing Condition Insurance Pools (PCIPs) created by the ACA. The federal government allocated $5 billion for high-risk pools in an effort to fully fund them until 2014, but the pools predictably turned out to be more expensive than anticipated. In March of this year, participating states were told that they could no longer enroll new enrollees. (3) Seventeen states turned over their high-risk pools to the federal government at that time. The basic story for high-risk pools is that they attract sicker people and soon run out of money. (4) A PCIP set up in Alaska under the ACA spent about  $10 million last year to cover only 50 members—about $200,000 per person. (5) 

The folly of this approach, as with other efforts to slice and dice the uninsured or underinsured in one way or another, is that it does not have to be this way. What if we had just one risk pool for all 310 million of us Americans? With only one insurer— national health insurance (NHI), single-payer Medicare for All—we would all pay less than we are now for a comprehensive set of benefits, with portability to all states and territories, with far less bureaucracy, more equity, reliability and sustainability. A single large risk pool would enable bulk purchasing power, protection with a solid range of coverage, full choice within one large network of physicians, other health professionals and hospitals, and effective cost controls in a more accountable system. (6)

Suggested Reading: 

  1. 1. American Diabetes Association. High-risk pools. Health Insurance Resource Manual. Alexandria, VA, 2006.
  2. 2. Girion, L. Healthy? Insurers don’t buy it. Minor ailments can thwart applicants for individual policies. Los Angeles Times, December 31, 2006.
  3. 3. Gordon, E. Pennsylvania among 17 states turning over high-risk pool responsibility to feds. Kaiser Health News, July 1, 2013.
  4. 4. Kenen, J. Revisit how high-risk insurance pools are working in your state. Association of Health Care Journalists. June 4, 2013.
  5. 5. Galewitz, P. Alaska to spend $200K a year for each high-risk pool member. The KHN Blog, January 17, 2012.
  6. 6. Geyman, JP. Health Care Wars: How Market Ideology and Corporate Power Are Killing Americans. Friday Harbor. Copernicus Healthcare, 2012, pp 205-10. 

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