More required reading on high risk pools

Republican attacks on (their own) high risk pool concept….

Slate‘s Tim Noah has a nice piece today on high risk pools (technically known as the Pre-existing Conditions Insurance Plan, or PCIP). His subtitle, “Republicans are right: Obamacare’s high-risk pools were a dumb idea. But it was their dumb idea,” expresses the main point.

Aaron Carroll over at the Incidental Economist picks up on this with another nice piece, noting that Austin Frakt had anticipated in his own research so many of the problems PCIP is now encountering. Leaving aside his celebrity blogger status, Frakt has done some of the best technical work on market demand for such policies. His research and web postings on this subject deserve an especially close look.

I myself have something in the pipeline at Kaiser Health News. I won’t spoil the punch line here. (The truly intrepid can read my recently published piece in the Journal of General Internal Medicine, which gives more descriptive prevalence information regarding the medically uninsured, including 95% confidence intervals and that sort of stuff.)

Some ironies jump out in this debate.

First, Republicans are suggesting that PCIP’s faults reflect the broader folly of health reform. Yet from the start, liberal policy wonks regarded PCIP as a troubled, stopgap measure to provide some immediate relief before health insurance exchanges and expanded Medicaid benefits become operative. Progressives rightly disliked the basic program design, which requires chronically ill people to go months without health coverage before they become eligible for help—help which was often valuable, but which was difficult for many people to afford. The poor track record of state high risk pools prior to health reform hardly increased anyone’s confidence. I myself am on record being harshly critical. I’m starting to feel badly about this, since good people are working hard to implement PCIP, and they’re taking unfair hits.

Then there is the fact Noah emphasizes: Republicans themselves made high risk pools the centerpiece of their own health reform plans. Had they won the 2008 election and pushed ahead with their plans, Republicans would have permanently embedded within our health financing system just about every flaw they now lament in our current, avowedly temporary PCIP program.

Many of PCIP’s problems reflect the inherent vagaries of a new complex and under-funded program, whose inherent logistical unpredictability is magnified because the program can serve a tiny fraction of the sick and uninsured: How will states target their very limited resources? Who will most aggressively sign up for this program?

Some of the same challenges will arise with the new CLASS disability insurance benefit. More about that on another occasion.

Author: Harold Pollack

Harold Pollack is Helen Ross Professor of Social Service Administration at the University of Chicago. He has served on three expert committees of the National Academies of Science. His recent research appears in such journals as Addiction, Journal of the American Medical Association, and American Journal of Public Health. He writes regularly on HIV prevention, crime and drug policy, health reform, and disability policy for American Prospect,, and other news outlets. His essay, "Lessons from an Emergency Room Nightmare" was selected for the collection The Best American Medical Writing, 2009. He recently participated, with zero critical acclaim, in the University of Chicago's annual Latke-Hamentaschen debate.

4 thoughts on “More required reading on high risk pools”

  1. I've heard numerous criticisms of the PPACA, noting that the high-risk pools are projected to be much more expensive than the original CBO projections. (And noting that this might reasonably imply that the plan's cost overall will be higher than estimated.)

    That's a criticism of cost projections, not high-risk pools. I'd be interested in a pointer to criticism of high-risk polls per se, from a Republican/conservative perspective.

  2. I'll have some of those links in my Friday column. In my view, you can't project much either way about cost from the 8,000 people now being served at this early stage in a complex program. This earlier column… has some links to a letter by 30 Republican senators about the program. May be helpful to you.

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