COVERAGE: Making the Grade

Last year, the Washington Post profiled ten area residents and asked them to rate their own experiences with various forms of health insurance. The average grade: just over a B minus. A year later, the Post checked in with some of those profiled to see how things had changed. The resulting updates, as well as the original profiles, provide a striking survey of the state of health insurance in America.

Here are some of common themes that stood out to us from the series:

• The advantages of the large-group market:
  Last year, Sam Atadjanov couldn't afford to cover his wife on the plan offered through his work at a small accounting firm. Now, as an employee of the Maryland Department of Health and Mental Hygiene, he has access to benefits of large group market (economies of scale, administrative efficiencies and more risk pooling) and can afford to cover his wife. Making the advantages of large-group insurance available to all Americans is a sound starting point for any sustainable reform effort.
• The changing nature of small-group coverage:
  While coverage in the large-group market remains relatively stable, Kaiser Family Foundation president Drew Altman notes the small-group and individual markets have seen dramatic changes in nature of insurance offered. The high cost of health care in a weak economy has led small business owners like Bruce Winter to seek savings in more limited, high-deductible plans. As Altman notes, the trend is not so much toward consumer driven health care, as it is toward bare bone policies with scant protection against high out-of-pocket costs.
• The limitations of the individual market:
  Insurers providing coverage on the individual market (which lacks some of the consumer protections of the group market) make their money primarily through risk selection and underwriting. As our colleague, Joanne Kenen noted earlier this week, that means higher costs for many women. It also means a lack of portability, as high-risk individuals like Chas Sforza, who suffered a heart attack last year and would have a high chance of being denied coverage if he had to go through underwriting in the individual market. So who does the individual market work for? Primarily, the young and healthy, like Justin George, who was able to find a cheaper plan on the individual makret, than the one offered by his work. But even those young college kids just off their parents' insurance, like Chris Basler who bought a bare bones plan, are at risk for injured ankles (and high out-of-pocket costs.)
• The importance of government programs like SCHIP and COBRA:
  Some of the problems with the portability of insurance are mitigated by government programs like COBRA which helped Ryann Galganowicz bridge the gap until receiving insurance through a new employer. Another government program, SCHIP was essential for Doreen Hodges to supplement her private health insurance and provide coverage to a family that includes a special needs child. Hodges' family lost its PPO coverage March. Like a third of all low-income families, she's had trouble paying medical bills and, as result, affording other necessities like food and gas.
• The high costs of health care even for those with insurance:
  Medical debt is a problem even for those with insurance. Jimmy and Jacqueline Eyler are covered through Jimmy's employer. But Jacqueline's breast cancer has forced them spend nearly $50,000 in savings and dip into their retirement funds. Next year doesn't look better, as Jimmy's employer plans to switch to a plan with even more employee cost sharing. The Eylers are part of what the Commonwealth Fund estimates are 25 million underinsured Americans—individuals with insurance who are still financially vulnerable to the high costs of medical care.

So how does the system look compared to a year ago? The simple answer is: incomplete. It's hard to come up with a GPA this year because the Post followed up with only some of those originally profiled. For those lucky enough to be young and healthy or recieve coverage in the large group market, things look OK. But for small businesses struggling to provide coverage or individuals battling a chronic and catastrophic disease—things are worse and show no signs of improving. Finally, all of these profiles are of individuals with insurance. Any true report card for health care in America must also take into account the 46 million for whom our health system fails to provide any coverage.