Have insurers found new ways to avoid the sick?

Obama administration is being pressed to enforce anti-discrimination provisions
FIT Staff
Aug 20, 2014


Ending insurance discrimination against the sick was a central goal of the nation's health care overhaul, but leading patient groups say that promise is being undermined by new barriers from insurers.

The insurance industry responds that critics are confusing legitimate cost-control with bias.

Some state regulators, however, say there's reason to be concerned about policies that shift costs to patients and narrow their choices of hospitals and doctors.

With open enrollment for 2015 three months away, the Obama administration is being pressed to enforce the Affordable Care Act's anti-discrimination provisions.

Some regulations have been issued; others are pending after more than four years.

More than 300 patient advocacy groups recently wrote Health and Human Services Secretary Sylvia Mathews Burwell to complain about some insurer tactics that "are highly discriminatory against patients with chronic health conditions and may ... violate the (law's) nondiscrimination provisions."

Among the groups were the AIDS Institute, the American Lung Association, Easter Seals, the Epilepsy Foundation, the Leukemia & Lymphoma Society, the National Alliance on Mental Illness, the National Kidney Foundation and United Cerebral Palsy. All supported the law.

Coverage of expensive drugs tops their concerns.

The advocates also say they are disappointed by how difficult it's proved for consumers to get a full picture of plans sold on the new insurance exchanges.

Digging is often required to learn crucial details such as drugs covered, exact copayments and which doctors and hospitals are in the network.

Washington state's insurance commissioner, Mike Kreidler, said "there is no question" that discrimination is creeping back. "The question is whether we are catching it or not," added Kreidler, a Democrat.

Kansas' commissioner, Sandy Praeger, a Republican, said the jury is out on whether some insurers are back to shunning the sick.

Nonetheless, Praeger said the administration needs to take a strong stand.

"They ought to make it very clear that if there is any kind of discrimination against people with chronic conditions, there will be enforcement action," Praeger said. "The whole goal here was to use the private insurance market to create a system that provides health insurance for all Americans."

The Obama administration turned down interview requests.

An HHS spokeswoman said the department is preparing a formal response to the advocates and stressed that today's level of consumer protection is far superior to what existed before President Barack Obama's law, when an insurance company could use any existing medical condition to deny coverage.

The law also takes away some of the motivation insurers have for chasing healthy patients. Those attracting a healthy population must pay into a pool that will reimburse plans with a higher share of patients with health problems. But that backstop is under attack from congressional Republicans as an insurer "bailout."

Compounding the uncertainty is that Washington and the states now share responsibility for policing health plans sold to individuals.

Although the federal government is running insurance markets in 36 states, state regulators are still in charge of consumer protection. A few states refuse to enforce any aspect of the law.

Kreidler said the federal government should establish a basic level of protection that states can build on. "We're kind of piecemealing it right now," he said.

Much of the concern is about coverage for prescription drugs. Also worrisome are the narrow networks of hospitals and doctors that insurers are using to keep premiums down. Healthy people generally shop for lower premiums, while people with health problems look for access to specialists and the best hospitals.

Before Obama's overhaul, insurance plans sold on the individual market could exclude prescription coverage. Now the debate is over what's fair to charge patients.

Some plans are requiring patients to pay 30 percent or more for drugs that go for several thousand dollars a month. HIV drugs, certain cancer medications, and multiple sclerosis drugs are among them.

Although the law sets an overall annual limit on what patients are required to pay, the initial medication cost can be a shock.

California resident Charis Hill has ankylosing spondylitis, a painful, progressive form of spinal arthritis.

To manage it, she relies on an expensive medication called Enbrel. When she tried to fill her prescription the pharmacy wanted $2,000, more than she could afford.

"Insurance companies are basically singling out certain conditions by placing some medications on high-cost tiers," said Hill. That "is pretty blatant discrimination in my mind."

Hill, a biking advocate from the Sacramento area, has been able to get her medication through the manufacturer's patient assistance program.

The insurance industry trade group America's Health Insurance Plans says there's no discrimination because patients have many options on the insurance exchanges. Gold and platinum plans feature lower cost-sharing, but have higher premiums. Standard silver plans generally require patients to pay a greater share of medical bills, but some have fairly robust drug coverage.

"There are plans on the exchanges that are right for people who have these health conditions," said Brendan Buck, a spokesman for the group.

For 2015, the administration says it will identify plans that require unusually high patient cost-sharing in states where Washington is running the exchange.

Insurers may get an opportunity to make changes. Regulators will collect and analyze data on insurers' networks.

"People who have high cost health conditions are still having a problem accessing care," said law professor Timothy Jost of Washington and Lee University in Virginia. "We are in the early stages of trying to figure out what the problems are, and to what extent they are based on insurance company discrimination, or inherent in the structure of the program."



Insurance Companies are getting paid and you are getting screwed! Maybe if they would have read the bill before voting on it we might have some sort of bill that helps people.
"The people are going to need insurance after the insurance companies get done raping them"


Insurance companies are in business to make money. Duh. For better or for worse, this article points to a push to move away from private insurance companies and toward a total government system.


Absolutely right. I have no ax to grind either way for insurance companies, but they are unquestionably being set up as the fall guys for the Obamacare debacle. I find it interesting that one of the main reasons touted for passing Obamacare was to "get the insurance companies under control." Well, here we are years later and those darn insurance companies are still running amok. As you say, once they have driven the insurance companies out of business and we have a one payer system (which has always been the goal of Obamacare), you have to wonder who they will blame then when things still don't work.

The Hero Zone's picture
The Hero Zone

It's just as disingenuous as making individuals and companies the fall-guys for all the "loopholes" they use in tax calculations. As if Congress wasn't the one who wrote them, renew them, or fail to amend them;nor the President for signing it or enforcing them.

Clearly it is the citizen entity's fault. Hah!


"Digging is often required to learn crucial details such as drugs covered, exact copayments and which doctors and hospitals are in the network." What? They expect people to actually read and learn the details of the contract they are signing? This is unconscionable.

I recently signed up for Medicare and its associated Medigap plans and spent days reading about and researching the various plans. This is called part of life and being responsible.


I agree will all of ya.......Donegan, Ohio and Justme.

I am for affordable health care of all legal Americans.
Ya gotta approve it before you can know what is in it. Kinda scary stuff our representatives do!
Not all people are as savvy as others. So, reading and understanding are two different things. I too read this stuff and ask questions. Some may not be as capable.
Yep. Insurance companies will try to find any way to not pay claims, like they have in the past.
If ya get over the government thing, I think a single payer is a very good way to go. Ya, I know, here come the comments. Lol


The single payer plan is positive because of the "non profit" aspect of it. But what is gained by making it non-profit will surely be lost since the government can NEVER run anything with cost containment in mind. So we are screwed either way.


Anyone that makes money is looked upon as a bad person by this administration.


Here's an idea: Let's determine the average annual income in America. And THEN let's require everyone who makes more than that to pay that much in taxes. Members of Congress would make the IDEAL test bed for such a redistribution program, don't you think?

Until multi-millionaires like Barack Obama, Nancy Pelosi, Harry Reid, etc. and so on agree that money is so evil they're giving up most of their own, I'm inclined to call them the hypocritical despots that they are!

The Answer Person



I understand the theory: When it comes to healthcare, the cost is prohibitive for many, and making it a non-profit industry seems like the solution. The problem is the government can't run anything within a budget, make cuts when necessary, etc. So it ultimately won't help the cost.


Maybe private company could manage it for the government.


Obamacare is not now, and has never been, about "controlling insurance companies." It's about putting insurance companies out of business and then saying, "Well, now we have no CHOICE but to go to nationalized healthcare!" Unless Obamacare is summarily ended, the dominoes will keep on falling until that's where the last one lands. And Justme is right: Government-run healthcare will be the single worst thing that's ever happened to the state of medicine in this country (not to mention overwhelmingly burdensome to the American taxpayer). Nice.


The state of medicine is bad in this country overall. The metrics show the US near the bottom of almost every category.....except cost. Gotta do something so all Americans get care.


Agree 100%. Our country's medicine has been out of control. All pay one way or another. Things must change.


Just lie to the public and lead them like sheep. The norm.