For some Idahoans, health insurance has a breaking point | Health ...

Brian Heffley?s whole family is riled up about health insurance premiums.

Last week, before taking his 4-year-old son to the hospital for hernia surgery, Heffley girded himself for what he predicts will be a nearly $10,000 out-of-pocket bill ? even with insurance.

Heffley?s premiums for a Regence BlueShield of Idaho plan that covers his family of five have risen fast. Heffley, a 34-year-old small-business owner, got estimates for his son?s surgery: ?$17,000 to $18,000 when all is said and done,? he said. ?It?s going to be disastrous.?

He is one of many Idahoans getting a jolt from premium increases well above the new 10 percent trigger for state and federal regulators to review them.

More than a dozen Idahoans who pay for their own insurance told the Statesman their rates are climbing 30 percent to more than 40 percent a year.

AS COSTS RISE, SO DO PREMIUMS

The rising cost of health care, and rising insurance rates, are persistent problems that Congress and the Obama administration sought to ameliorate by creating the Affordable Care Act, the 2010 health care reform law known by some as Obamacare.

Spending on health insurance premiums slowed a bit in the U.S. in 2010 but still grew about 2.4 percent that year, according to federal data. There was ?a decline in private health insurance enrollment, increases in cost sharing and a shift by some consumers to plans with lower premiums,? according to the Centers for Medicare and Medicaid Services.

Some of the Affordable Care Act?s provisions have already kicked in. They include some free preventive care, help with a Medicare coverage gap, insurance for children on their parents? plans up to age 26, and reviews of any insurance rates that go up 10 percent or more in a year.

Other provisions, like an expansion of Medicaid by as many as 16 million Americans, will take effect in 2014 if the Supreme Court upholds the law.

The law also limits how much of their members? premiums health insurers can keep. The top insurers in Idaho have kept around 15 to 20 percent of what they collect from Idahoans ? in line with the new legal limit ? to pay for salaries, taxes, marketing and other overhead. The insurers, not-for-profit entities, can have surpluses and investments.

Regence kept about $95.4 million and Blue Cross of Idaho kept about $144.8 million in 2010, according to state records. The remaining 80 percent goes to medical costs and related services, which are getting more expensive, insurers said.

Most rate increases are basically pass-throughs of people using health care more, and the cost of that care getting higher, according to insurance companies.

That is why people like Guy Jenkins go to great lengths to avoid medical claims that could raise their rates. They skip seeing the doctor or giving the pharmacist their insurance cards.

Jenkins? great length is about 4,700 miles. He gets his checkups in England.

A TROUBLED PLAN

Heffley?s mother-in-law, Nancy Hersage, a Meridian woman in her early 60s, held on to health insurance by changing her plan, doubling her deductible to $5,000 and switching insurers.

The $277 she paid each month to Regence BlueShield of Idaho in September 2009 for a $2,500 deductible went up to $358 the following year.

At first, she tried to fight it.

Hersage wrote to the Idaho Department of Insurance about the 29 percent spike in her premium for Regence?s SelectNow plan, which covers six office visits a year and limits laboratory and brand-name drug payments.

The department told Hersage that Regence had ?severely underpriced? the plan when it started selling it. Regence says it took a $3 million loss on its entire line of individual plans last year.

The company filed ?an extreme increase (of 100 percent or more) ... to make up for the losses and estimated future claims? in SelectNow, the department said. The department denied the request, saying people couldn?t afford rates ballooning that much.

No law limits the increase a company could apply in that situation, the department said, but it negotiated with Regence to raise rates 25 to 30 percent a year over four years.

The negotiated increase accounted for most of Hersage?s 2009 increase. Four additional percentage points were tacked on because she got older. None of her rate increase was due to her own health or claims history, the department found.

Hersage was livid. She demanded to know if the department had ?been protecting my interests.?

The department said it isn?t a consumer protection agency. ?I have had many complaints this year about NowSelect plan increases where the total increase was closer to 50 percent because of the insured (person)?s health status,? Eileen W. Mundorff, consumer affairs officer, said in a letter to Hersage.

The department?s powers are limited by law, Mundorff wrote, adding that ?until the Legislature can pass laws that improve consumer rights in health insurance, we do not have the jurisdiction to order companies to make changes where there is no violation of law.?

Hersage decided to take a bigger risk with her deductible and switch to Blue Cross of Idaho. That reduced her monthly premium the following year to $341. But with 12 of those payments a year and a $5,000 deductible, she noted with resignation that she still must pay $9,000 before insurance would cover any health catastrophes this year.

Jay and Roberta Olson moved to Boise from Oklahoma and bought the NowSelect plan in fall 2008. It cost about $232 a month for Jay, 58, a licensed anesthesiologist, and $224 a month for Roberta, 62, a mostly retired psychology professor.

By the third anniversary of their plans, their health hadn?t changed but their NowSelect premium had soared to $577 and $533 a month. That?s when they decided to drop it. They shopped around and, like Hersage, got a cheaper Blue Cross of Idaho plan.

The Olsons, too, complained to the Department of Insurance. ?If the electrical utilities were raising rates 35 percent a year, heads would explode,? Jay said. ?This is pricing people out of health insurance in Idaho.?

HOW HEALTH REFORM CHANGES PREMIUMS

Insurance rates go up or down based in part on a person?s individual habits and traits and those of others with the plan, according to Idaho health insurers.

But rates also are directly affected by people who don?t have insurance at all. That was one argument made by U.S. Solicitor General Donald Verrilli when the Supreme Court spent a history-making three days last week on the 2010 health care reform law.

The health care marketplace is unusual in that almost all Americans use it before they die, but not everyone has insurance to pay for it, Verrilli said. (In Idaho, about one in five people aren?t covered if they have a medical problem.) The costs they incur don?t disappear.

Those ?many billions of dollars of uncompensated costs are transferred directly to other market participants,? Verrilli said. ?Health care providers charge higher rates in order to cover the cost of uncompensated care, and insurance companies reflect those higher rates in higher premiums, which Congress found translates to a thousand dollars per family in additional health insurance costs.?

But Paul Clement, a lawyer for Florida and other states, including Idaho, that are fighting the law, said any decision an American makes will ripple through industries and affect taxpayers. If a citizen decides not to buy a car, it could put an auto worker on welfare, he said.

Clement said the ?much bigger cost-shifting? problem is ?when you force healthy people into an insurance market precisely because they?re healthy, precisely because they?re not likely to go to the emergency room, precisely because they?re not likely to use the insurance they?re forced to buy ... That creates a huge windfall. It lowers the price of premiums.?

WHY YOUR PREMIUM IS WHAT IT IS

When the Heffleys moved to Idaho in July 2009, their plan cost $279 a month. The next year, they paid about $400. They had a third child in May 2010, which added to the premiums.

August brought another rate increase. The monthly premium is now $644.14 a month with a deductible of $7,500 per person or $15,000 for the family and a 20 percent co-payment.

Three major factors usually go into each person?s insurance rate, said Georganne Benjamin, spokeswoman for Regence:

? The overall health of everyone covered under that kind of plan.

? The person?s age.

? The person?s health status.

?So if a person did not incur any claims and did not change age brackets, they could still see a rate increase because of everyone else who is covered (by that kind of plan),? she said.

The NowSelect plan is a good example.

NowSelect hit the market in 2006 as a ?competitively priced? plan that gave people limited coverage, Benjamin said. The company had done a market analysis to find out how popular the plan would be. But it didn?t expect a wave of people with ?health issues (incurring) more costly health care services? would sign up for the plan, she said. Premiums had to change.

So even without an age-bracket change or any visits to the doctor, someone like Hersage could get an unpleasant surprise at renewal time.

People with costly medical conditions can save money, insurers say. While rates will go up for a person who is diagnosed with cancer, it?s ?pretty much likely that while they?re covered by Blue Cross of Idaho, they are going to use well over 10 times what they pay in,? said Blue Cross of Idaho spokeswoman Karen Early.

That?s how the insurance pool works, and why someone healthy ends up paying more.

HOW THE STATE HANDLES COMPLAINTS

Idahoans complain every year to the Idaho Department of Insurance about their individual or group health insurance plans.

The department investigates consumer complaints, said Amy Lambrecht, consumer affairs supervisor. A person first must submit a written complaint. The department will contact the company and look for two things: violations of the Idaho insurance code and violations of the insurance contract.

If the department starts getting a lot of complaints about a specific plan or against a single company, ?we usually take a much deeper look at that,? Lambrecht said.

That can mean looking at insurance rates and forms, getting proof of costs or other documentation. The department also routinely checks insurance rate filings to make sure they?re not illegal or discriminatory.

Under the Affordable Care Act, the department and federal health officials have started checking more rates, and if a small-group or individual insurer is spending less than 80 percent of its premiums on actual medical care, it must give refunds, lower rates or explain why it won?t. Two out-of-state insurers doing business in Idaho were told last month to do that.

VACATIONING AT THE DOCTOR?S OFFICE

Guy Jenkins, 47, is British, but he?s lived in the U.S. for 16 years. He moved his painting-contractor business to Boise from Colorado in 2009.

Jenkins is a loyal customer of various companies, rattling off the number of years ? all over 10 ? that he?s been with DirecTV, Sprint and State Farm. Then he gets to health insurance. He?s loyal there, too ? 10 or 11 years with Wisconsin-based Assurant Health ? but not happily so.

He?d been paying a quarterly premium of about $400 to $450 in Colorado. After he moved to Idaho, the premium shot up to $605. This year, it?s $869.

He wonders if getting a spot on his back checked out, a ?venture (that) cost me $450? after insurance, was the reason. That visit was an exception to a record largely devoid of medical claims, he said.

Usually, about once a year, he flies to England. He sees family and spends a day making the rounds to the dentist, eye doctor and his primary-care provider of about 30 years.

Jenkins said he still pays taxes into the nationalized system he grew up with. The British system relies on taxpayer funding and charges patients in the United Kingdom nothing for most services. The system?s budget is about $2,700 per person. (Total health spending in the U.S. was about $2.6 trillion in 2010, or $8,402 per person. The federal government, mainly through Medicare and Medicaid, financed about $2,437 of that average.)

Still, Jenkins is grateful to be insured in the U.S. in case something goes wrong.

?It?s like a mill stone which I?ve got to have. But,? he said, ?I?m lucky in that I can scrape (the premium) together.?

This week, as Heffley?s son starts a long recovery, Heffley thinks the high deductible he?s about to pay for the hernia surgery will end up being more affordable than a better plan with higher premiums. He?s taking a gamble along with other Idahoans who buy catastrophic plans, hoping the surgeries and accidents will stick to an every-few-years schedule.

?I?m worried about the future, big time,? he said.

Audrey Dutton: 377-6448

attwireless taylor swift zac efron the scream stephen colbert new madrid fault rihanna and chris brown affirmative action