Is reform adequately serving people in your area with pre-existing conditions?


This post is about high risk pools, so let’s get some confusing semantics out of the way.

The Affordable Care Act created special pre-existing condition insurance pools (known as PCIP).  But many states already had high risk pools. The older state-based high risk pools (sometimes called legacy pools) still exist … but to further complicate matters, the health law gave states the option of running their own PCIP or having the feds do it. So some states have two state-run pools:  one “high risk” and one “PCIP.” Some states have a “high risk” and the feds run the “PCIP.” And some states don’t run a high risk pools so they only have a PCIP – which either they run, or the federal government runs.  Got all that?

What questions do you have about Health Policy and how to cover it?

Joanne KenenJoanne Kenen is AHCJ’s health reform topic leader. She is writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of Health Policy. If you have questions or suggestions for future resources on the topic, please send them to

When the health care law passed last year, it included $5 billion for temporary insurance pools for uninsured people with pre-existing conditions.  The widespread expectation was that the uninsured would rush to enroll, blowing through the $5 billion long before 2014, when the pools were supposed to shut down as national reform kicked in.  Once the state exchanges are up and running, the uninsured will be able to buy coverage that way (with subsidies if they qualify based on income) and can’t be turned down because of pre-existing conditions or high-risk.

The conventional wisdom was wrong; enrollment in the pools was a trickle, not a flood.  HHS has twice  – once last fall and once just a few weeks ago – announced steps to bring down premium costs and streamline enrollment. The pace of enrollment has picked up a bit, but it’s still just about 20,000. That’s total, nationwide. (The health insurance law gave states the option of running the pre-existing pool, or having the federal government do it. Either way the feds fund it, with participants also paying premiums.)

The main barrier, of course, is cost – premiums in the pools are high. And people have to be uninsured for six months to get into the pre-existing condition pools. That means people who have decided to pony up for the older state high risk pools (which exist in 35 states and were created long before Health Policy) aren’t going to drop coverage and go without for six months so they can get into these newer federally funded pools, even if the new ones are less expensive.

The states running the pools, as well as their federal partners, have begun trying to do more outreach. In one little-noticed provision, HHS this fall will start paying insurance agents and brokers for connecting eligible uninsured people with the program.

Is any of this outreach happening in your state? Is it visible? How are people hearing – or not hearing – about the pools. Why are they staying uninsured rather than going into the pools. Obviously cost is a factor – but is anything else at play?  Is the outreach adequate? What are the misperceptions?  What is the psychology? Are they just crossing their fingers and hoping they don’t get sick, or are they assuming they can get free or charity care in the ER in a crunch? Are they going to community health clinics rather than pay the high cost of the pools?

To learn more about high risk pools, here are some resources.

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