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Health & Fitness

Insurance a relief for people with pre-existing conditions

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Published:   |   Updated: September 17, 2013 at 09:42 AM

ST. PETERSBURG — Bob Linde has survived nearly a decade without health insurance.

A lot of people think Linde, a licensed acupuncturist and herbalist, doesn't want to pay a monthly premium for the Western medicine he doesn't practice. A healthy diet, acupuncture and plant-based remedies seem to be working just fine.

But the 50-year-old wants insurance in case catastrophe strikes. What if he's hit by a truck or diagnosed with cancer? His financial security and business would be destroyed, he said.

It's the medical conditions he developed 20 years ago while serving in the Army that keep insurance out of his reach. Linde is one of many veterans who suffer from chronic joint pain and respiratory and gastrointestinal discomfort — a medically-unexplained illness called Gulf War Syndrome.

Since the ailments made it onto his medical record, insurance companies have denied him coverage altogether, or he's been offered policies so costly it would bankrupt the business that took years to establish, he said. “I think of myself as a very healthy person, and yet there's that nagging doubt. What is it that I don't know? What is it that I don't see? What happens if I'm driving carefully down the road and a drunk driver comes out of the blue. I can't do anything,” said Linde, owner of Acupuncture & Herbal Therapies in downtown St. Petersburg.

That's a big reason why Linde is looking forward to Jan. 1 and the launch of major portions of the Affordable Care Act. From that day on, it will be against the law to discriminate against or deny any American health insurance coverage based on a pre-existing medical condition.

Linde and millions of other Americans with pre-existing conditions could be on the winning end of the health care reform law passed in 2010. For years, many of the chronically sick have been denied coverage because of an old illness or injury, or they've been charged premiums so high, it made no financial sense to sign up.

The law will significantly lower monthly premiums for these high-cost, high-risk individuals.

“To know that I've got a safety net, ultimately just some basic insurance that covers that kind of catastrophic kind of issues, it does give you peace of mind. It does make it a little easier to sleep at night sometimes,” Linde said.

It's hard to say how many people are denied insurance on account of a pre-existing condition, but stories of people fighting an insurance company over an old ailment — or tales of bum knees or other limbs being tossed into “body part” exclusions — are plentiful.

Tampa resident Michelle Pretelis said a bout with thyroid cancer stopped her from getting comprehensive medical insurance. The 58-year-old pays a $65-a-month premium for a basic preventative care policy, and that's only because she had that plan prior to her diagnosis and treatment, she said.

“They have just blocked me out,” said Pretrelis, who is a full-time caregiver for her elderly mother. “I couldn't get any other coverage.”

The U.S. Department of Health and Human Services last year estimated that between 50 million and 129 million Americans (19 to 50 percent) live with a chronic condition insurers might consider “pre-existing,” such as diabetes, heart disease, asthma or cancer. Last month, 57 percent of Americans surveyed in a Kaiser Family Foundation Health Tracking Poll said at least one member of their family has such a condition.

Many are middle-aged, in the 50- to 64-year-old age range not yet eligible for Medicare, the government's health care for seniors. Some of these working-age adults discover that their desire to get back on the job is hampered by a condition they can't afford to treat.

Kidney stones, chronic arthritis in his hand, and now high blood pressure are keeping Dory “Frank” Dixon from being a chef. When the 43-year-old Brandon resident was able to work, he paid $53 every two weeks for health insurance.

“It's hard to use my hands now,” said Dixon, a patient at the Brandon Outreach Clinic for uninsured local adults.

Dixon said estimates that coverage on the federally run Healthcare Marketplace would cost $55 a month might be affordable. He said he and his wife, a beauty shop owner, think they could manage $100 a month to cover them both.

“Who doesn't want to be healthy?” he asked.

In theory, guaranteeing affordable coverage for these individuals makes sense. But it's an incredibly complex and politically charged issue that will be essential to the success or failure of the law commonly known as “Obamacare.”

If the Affordable Care Act is to succeed, something — or someone — will have to make up for the lower costs those with pre-exisiting conditions will see, said Princeton University economist Uwe Reinhardt.

Enter the “young invincibles”: healthy, low-risk young adults.

Reinhardt said this is the demographic most likely to get “sticker shock” from the changes. Many who didn't have insurance at all now will have to pay a monthly premium. And healthy adults who had minimal coverage will see their premiums spike, he said.

“Premium shock refers to the healthiest people,” he said. For those with chronic conditions, watching others pay more will be a novelty, he said.

Brooke and Andrew Lee got a double whammy when they tried to add maternity care to Brooke's individual insurance policy a few years ago. The couple, self-employed owners of Roundhouse Creative in St. Petersburg, found out that an illness Brooke had years ago was showing up as a pre-existing condition.

Add to that the problem that maternity care was covered only if the couple started paying a higher monthly premium at least six months prior to a baby's conception. (Starting in 2014, pregnancy and maternity care will no longer fall into pre-existing categories.)

“It shouldn't be that stressful and difficult to bring a baby into the world,” Andrew Lee, 33, said of the experience.

After weighing the options on multiple spreadsheets, the couple opted to pay out of pocket and negotiate payment plans with doctors and the hospital. The $8,500 price tag added up to less than the premiums and deductibles they would have had to shell out for an expanded insurance policy.

“Thankfully, we had a healthy pregnancy,” Brooke Lee, 36, said of the birth of son Indio nine months ago.

Medical complications during pregnancy or the possible reoccurrence of an illness explain why insurance companies have been reluctant to assume the financial risk of taking on individuals with pre-existing conditions. Recent government-backed attempts to cover these individuals also show how difficult the changes may be to execute.

The Affordable Care Act in 2010 created the Pre-Existing Condition Insurance Plan, an opportunity for people with serious pre-existing conditions to buy health insurance in Florida and dozens of other states.

A total of 10,402 Floridians signed up for the plan, which charges from $136 to $432 a month. Participants pay 30 percent of their medical costs after meeting a $2,000 deductible and $500 prescription drug deductible.

But in February, with more than 104,000 enrollees nationwide, the government stopped accepting any new participants, citing financial concerns.

Still, the online health insurance marketplace that opens Oct. 1 will accept eligible participants with pre-existing conditions for its 2014 policies, according to healthcare.gov.

The Lee family, which now includes baby Indio on a family policy, isn't sure how they will be covered next year. Right now they pay a $699 monthly premium, and maternity care is not included.

Both the negative experience with maternity care and the five-year debate over the Affordable Care Act make them reluctant to investigate how reform will affect their bottom line, Brooke Lee said.

“Honestly, I got tired of the political squabbling, and not knowing how it is going to end up,” she said.

Linde, the Asian medicine physician and business owner, has a different take.

“You know, health is a scary, scary enterprise. So I'll sleep better, you know, when there's a safety net — not just for me, but for the people I work with, because they are vital cogs in my business as well,” he said. “I'm looking forward to the changes.”

mshedden@tampatrib.com

(813) 259-7365

Twitter: @MaryShedden

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