Posted on December 15, 2002

Golden Rule successful in avoiding paying for breast cancer treatments


The New York Times
December 15, 2002
When Health Coverage Is Decided by the Calendar
By Michelle Andrews

People play chicken with their health insurance all the time. They leave their jobs and their employer-sponsored health plans, gambling that they won't be in an accident or become seriously ill before they get another job that has a group plan.

A gap in coverage, even for just a few months, could leave people responsible for certain medical bills for up to a year.

Blame the Health Insurance Portability and Accountability Act of 1996, known as Hipaa, a law that was intended to protect people when they switched plans. The law safeguards coverage for pre-existing medical conditions after a worker joins an employer's group health plan - as long as there has been no significant break in coverage. (Any period of more than 62 days is considered significant under Hipaa.)

With the economy still in turmoil and jobs harder to find, more people are failing to make this seamless transition. Many cannot afford to extend health insurance under the federal law known as Cobra, which lets workers continue policies for up to 18 months if they pay the full premiums.

Once someone has a new job, Hipaa loopholes may still be a problem. If an employer bought insurance through an association - one in four employers buys health coverage this way, as do many freelancers and small-business owners - an employee may not have the same protections as under regular group coverage.

"Associations label these plans 'group coverage' to make people think they're getting the protections they would have if they got coverage through an employer group plan," said Mila Kofman, an assistant research professor at the Institute for Health Care Research and Policy at Georgetown. "Consumers need to understand that's not the case."

When Michael Opelski, 38, of Norristown, Pa., started a new job as a sales representative for a home hardware manufacturer in the summer of 2000, he took the Golden Rule group plan offered by his employer. To get Golden Rule coverage, however, he first had to become a member of an association called the Federation of American Consumers and Travelers. Mr. Opelski said he hadn't given it a thought. But when his wife, Jean, became sick with inflammatory breast cancer, he learned how restricted his coverage was. Because Mrs. Opelski had discussed finding a lump in her breast with her doctor before joining the plan, Mr. Opelski said, Golden Rule refused to pay for her breast cancer treatments. It was a pre-existing condition, he said he had been told. She died in January at the age of 34.

If the couple had been covered by a regular employer group plan, Mrs. Opelski's breast cancer would probably have been covered under Hipaa. But their plan was something that Golden Rule calls an association group policy.

Is anyone calling for any revisions to Hipaa to close these loopholes on pre-existing conditions? If anything, political momentum is moving in the opposite direction - toward less comprehensive coverage and fewer safeguards and protections.

Coverage gaps may be among the least of our worries.

Comment: Association health plans (AHPs) are being promoted as an answer to the problem of obtaining access to affordable insurance for individuals and small businesses. Theoretically, AHPs would provide the advantage of lower premiums through group purchasing. In fact, AHPs often escape some of the regulatory oversight of state agencies, allowing plans that leave large voids in coverage and that are relatively free of "government mandates." These plans might offer lower premiums than the individual market, but both financial security and health security are threatened by AHP policies.

Currently, "political momentum is moving... toward less comprehensive coverage and fewer safeguards and protections." Do we really believe that the answer to our health insurance crisis is to disassemble the system and throw the infirm to the mercies of our ever-less-compassionate society? If we are truly compassionate, then why do we support policies that nurture the money managers in health care while simultaneously supporting policies that further impair affordability and access for those with the greatest health care needs?

We already have enough resources. But we need a single, publicly-administered system of funding health care to be certain that our resources our used to fulfill our mission of providing comprehensive health care coverage and access for everyone. It's our money. Shouldn't we be demanding value for our health care investment?