PPACA: Court Could Kill PCIP

WASHINGTON (AP) — Cancer patient Kathy Watson voted Republican in 2008 and believes the government has no right telling Americans to get health insurance. Nonetheless, she says she'd be dead if it weren't for the Patient Protection and Affordable Care Act (PPACA).

Now the Florida small businesswoman is worried the Supreme Court will strike down her lifeline. Under PPACA, Watson and nearly 62,000 other "uninsurable" patients are getting coverage through a little-known program for people who have been turned away by insurance companies because of pre-existing medical conditions.

"Without it, I would have been dead on March 2," Watson said of the Pre-Existing Condition Insurance Plan (PCIP) program. That's when she was hospitalized for a life-threatening respiratory infection.

It's not clear how the U.S. Supreme Court will rule on PPACA, but Watson's case illustrates the potential impact of tying everything in the far-reaching legislation to the fate of one provision, the unprecedented requirement that most Americans carry health insurance.

PPACA's opponents say if that insurance mandate is found to be unconstitutional, the rest of the law should also go, since courts should not be picking and choosing policy and drafters failed to include provision declaring that the rest of the law should stay in effect if some parts are thrown out.

The Obama administration defends the insurance requirement but says that, if the court decides to overturn it, most of the rest of PPACA should stay.

States can choose between administering their PCIP programs or letting the federal government provide PCIP services for their residents.

Officials in the 27 states that run their own PCIP programs are trying to make fallback arrangements in case the law is invalidated and coverage suddenly terminates.

"Some of these individuals are critically ill and are being treated for very serious illnesses, whether it be cancer or HIV-AIDS, and we feel a responsibility to them to do what we can to see they don't lose access," said Amie Goldman, who oversees PCIP in Wisconsin.

The federal officials who administer the plan in the other 23 states and the District of Columbia remain mum on what might happen there if the law is overturned.

The White House line is that Obama is confident the Supreme Court will uphold PPACA, and that his administration therefore is making no contingency plans for a reversal. None of that sounds reassuring to Watson, who owns a medical transport service in rural north-central Florida.

"It's scary," she said. "They need to look at this carefully because it is going to affect a lot of people with a lot of bad conditions who are not going to have any health care coverage."

Before PCIP, Watson had been uninsured since 2003, originally turned down because of elevated white blood cells. About three years ago, she was diagnosed with a chronic form of non-Hodgkin's lymphoma, a cancer of the immune system. Unable to afford medications, she relied on the emergency room to treat flare-ups.

She tried applying to a major insurance company for a small business plan for her and her employees, and was quickly rejected. Then she heard about PCIP.

The temporary program is meant to serve as a patch until 2014, when the federal health care law will require insurers to accept all applicants, including cancer patients like Watson, regardless of medical history. The law's controversial mandate for individuals to carry health insurance is related to that guaranteed acceptance provision. By forcing healthy people to buy insurance, it would help keep premiums in check, provision supporters say.

PCIP enrollment has been lower than expected, but the individuals who have enrolled have been sicker than expected, with medical expenses averaging about $29,000 per year. Federal officials recently said they would be eliminating a PCIP broker incentive program that paid agents and brokers a small, $100 fee to help consumers enroll. Brokers than reported that they had heard of few instances of brokers successfully collecting the fee.

Those brokers said they would like to get the fee but helped consumers find the program because of a concern that, for some consumers, PCIP is the only option.

Initially, Watson could not afford the $800 monthly premium the government was asking for PCIP. High premiums are part of the reason the program has not attracted more people.
But officials retooled to make coverage more affordable. Watson applied again and was accepted. She met the basic requirements: uninsured at least six months, turned away because of pre-existing conditions, having U.S. citizenship or legal residence. Her premium is $363.

In March, Watson went to the emergency room with what she thought was pneumonia. She was admitted, and quarantined the next morning when tests showed she had an antibiotic-resistant bacterial infection, highly dangerous. She spent five days in intensive care.

Without her PCIP coverage, Watson is convinced she would have been sent home from the emergency room after initial treatment to ease her shortness of breath.

"I'm not a candidate for any for type of indigent program, and without insurance they would not have put me in ICU," she said.

"I would have gone into cardiac arrest and probably died," she added. Emergency rooms must treat the uninsured, "but they are only required to get you stable. And then they release you and tell you to go to the health department."

A government report this year found that people in PCIP tended to be middle-aged patients with no access to employer coverage and with medical conditions that require continuous care. The top five diagnoses: Cancer, heart disease, degenerative bone diseases, organ failure requiring a transplant and hemophilia.

If the federal law is struck down, some state officials are considering taking the patients into their own, separate, state high-risk insurance pools. Wisconsin, for example, has decided that PCIP enrollees would be automatically accepted into its pool. But not all states have them. In the 35 that do, premiums would generally be higher, and there might be waiting periods.

Republicans, including presidential candidate Mitt Romney, have long favored insurance pools for high-risk patients. And Congress could take emergency action to keep PCIP going. But no assurances have been offered. Michael Steel, a spokesman for House Speaker John Boehner, says Republicans are ready to work on "step-by-step, commonsense" approaches.

Watson says she still disagrees with Obama's requirement that individuals have health insurance, either through an employer, a government program or by purchasing their own plan. "I approve of some of it," she said of the law, "I don't approve of the mandatory … insurance."

But she doesn't want to go back to depending on the emergency room.

"I have no problem paying my insurance and paying my copays," she said. "I just think I should have the right to purchase insurance."

Allison Bell contributed information to this report.

-ab