After Joe Sellers was diagnosed with leukemia, he was able to get decent health insurance for his wife and children, but not for himself.

Plan covering pre-existing conditions not a perfect remedy

After Joe Sellers was diagnosed with leukemia, he was able to get decent health insurance for his wife and children, but not for himself.
After Joe Sellers was diagnosed with leukemia, he was able to get decent health insurance for his wife and children, but not for himself.

Joe Sellers sees himself as a square peg fitting into a round hole of health insurance.

A real estate agent in the northern Atlanta suburbs, Sellers was diagnosed with leukemia in 2009. The next year, his health insurance company said it was going bankrupt, and he lost that policy.

So Sellers, middle-aged and self-employed, had to scramble.

He was able to buy an adequate plan for his wife and children. But with his pre-existing condition, he was basically uninsurable. All he could get for himself was a barebones policy, called ‘‘limited benefit.’’ (Here’s a USA Today article about these plans.)

Sellers went looking for what he calls ‘‘a regular job, so I could get group coverage.’’ But in a very difficult economy, there were few opportunities.

Later, he looked into the government’s Pre-Existing Condition Insurance Plan, designed for people, like himself, with health problems. But Sellers had insurance — albeit threadbare –- and thus was told he did not qualify. PCIP requires a person to be uninsured for at least six months to be eligible for enrollment.

Enrollment, and costs, picking up

PCIP, launched under the 2010 health reform law, got off to a very slow start in Georgia and elsewhere.

But last week, the federal government announced that nearly 50,000 Americans have now enrolled in  PCIP. And the number of Georgians in the state’s ‘‘high-risk’’ pool for people with pre-existing health conditions has nearly tripled in less than a year, to 1,476.

As of March 31, 2011, Georgia had just 515.

Georgia’s current number in PCIP is similar to enrollment in other states’ high-risk plans that were set up prior to the health care reform law, says Bill Custer, a health insurance expert at Georgia State University.

Reasons for the increase in enrollment include the feds’ lowering the monthly premiums for  PCIP in Georgia and showing more flexibility on how a person demonstrates a pre-existing condition, says Cindy Zeldin, executive director of the consumer advocacy group Georgians for a Healthy Future.

Another factor, she says, is more publicity about PCIP. ‘‘The word has gotten out a little more,’’ she says.

Twenty-seven states are operating their own PCIP program, often linked with existing ‘‘high-risk’’ insurance pools. Georgia, 22 other states and the District of Columbia have federally operated program.

Many of the enrollees are 45 years of age and older, but still are not old enough to be eligible for Medicare.

And many, like Sellers, now 46, have cancer.

In covering such serious medical conditions, PCIP’s health care costs for enrollees are expected to be more than double the amounts initially predicted for the program, the Washington Post reported.

Some don’t have time to wait

PCIP’s coverage would be a definite upgrade from Sellers’ current policy, which would pay just $30,000 for a hospital stay and $5,000 for an injury.

He does not have the practical option of dropping his current policy and then waiting six months. His doctor told him in December that he needed to start treatment immediately, Sellers says.

The six-month waiting period is a barrier for people such as Sellers, notes Custer.

The health reform law, which will be fully implemented in 2014 unless derailed by the Supreme Court or Congress, would resolve Sellers’ problem by allowing him to enter an insurance exchange.

‘‘The law is intended to prevent situations like his,’’ Custer says.

Sellers, a Republican who lives in Kennesaw, says he’s not exactly enamored of the health care law, known officially as the Affordable Care Act. He sees it as too rigid. But he says government should be able to help ‘‘square pegs’’ such as himself.

“When a person has exhausted all other means, our government should step up and take care of those people who can’t take care of themselves.’’

He recently received a big break when a drug company agreed to give him a chemotherapy drug free of charge. Normally it would have cost $30,000 over six months, he says. “It was a gift from God,’’ he says. Sellers adds that family and friends have offered to help, too.

But he worries about the possibility of getting an infection and being hospitalized –- and the resulting out-of-pocket costs.

PCIP is ‘‘a great idea,’’ Sellers says, but it needs to be more flexible. “This is not a Republican or a Democrat thing,’’ he says. “I’m the guy with cancer in the middle.’’