About 50,000 Americans who previously were uninsured are now covered under a program created by the Affordable Care Act, according to a report issued Feb. 23 by the Health and Human Services department.
The Pre-Existing Condition Insurance Plan (PCIP) initially was not well subscribed, and even now, has enrollment well below what the Obama Administration had predicted when health reform was passed in March 2010.
Enrollment was lower than expected for a number of months, but then took off in August 2011. Since then applications to the program have averaged about 8,000 per month, according to Steve Larsen, Deputy Administrator at the Centers for Medicare and Medicaid Services and Director of the Center for Consumer Information and Insurance Oversight.
CMS has been working with states, health care providers, federal agencies such as the Social Security Administration, and insurers to publicize the program’s existence, Mr. Larsen said. Some insurers have agreed to refer people to the PCIP who have been denied coverage. "The enrollment rates we’ve seen shows that over time there’s a greater rate as word gets out."
The program is open to anyone who has been uninsured for at least 6 months, has a pre-existing condition or has been denied health coverage because of a health condition, and is a U.S. citizen or legal resident.
Enrollees pay premiums that are similar to those paid by healthy people in the individual insurance market. They may pay more based on age, geographic area, and tobacco use. Out-of-pocket expenses are limited by law each year; in 2010 and 2011, this amount was $5,950; in 2012, it is $6,050.
Twenty-seven states run their own plans, and 23 states and the District of Columbia have plans operated by the federal government.
The Affordable Care Act appropriated $5 billion to pay out claims. So far, the program has spent $600 million, Mr. Larsen said. When asked whether the remaining funds would be enough to cover claims through 2014 – when enrollees will be transitioned to the state health exchanges – Mr. Larsen did not give a direct answer, but said that the program was managing so far.
Costs for enrollees have been higher than anticipated, possibly because of deferred health care prior to their enrollment, he said. They had more than 1.5 times as many claims, office visits, emergency room visits, and procedures as enrollees in the Federal Employees Health Benefits plan, and more than five times as many hospital admissions. The pre-existing plan enrollees were 3.5 times more likely to have claims of more than $10,000.
More than three-quarters (78%) of the costs for enrollees in the federal PCIP were for four conditions: cancer (27% of total); circulatory system conditions such as coronary artery disease (19%); rehabilitative care and aftercare, such as postsurgical care and certain forms of radiation and chemotherapy (18%); and degenerative joint diseases, such as osteoarthritis (14%). Extrapolating the known numbers of people with these conditions in the federally run plans, the report estimates that the PCIP program served nearly 1,900 people with cancer and 4,700 with heart disease in 2011. Other prevalent conditions included organ failures requiring a transplant, and hemophilia.
The largest proportion of PCIP enrollees are over age 55 years. The report said that these enrollees are likely "retired or no longer working, do not have access to employer-sponsored health insurance, and have not yet reached the age when they can enroll in Medicare."