If it hadn't been for a Minnesota health insurance program for high-risk patients, Caroline Winslow would have long ago moved to Wisconsin.
"I couldn't do it because of the existence of MCHA," Winslow said.
Aimed at helping people who have been turned away by insurers for pre-existing conditions, the Minnesota Comprehensive Health Association, a program has been a lifeline to people like Winslow. After becoming self-employed 15 years ago, she was denied for commercial insurance because she'd had several joint replacements. Her only option was MCHA.
"It really has kept me here," said Winslow, of Woodbury, Minn.
Minnesota's "high-risk pool," as it is known, is 37 years old and has 26,000 participants, making it one of the largest and oldest in the country.
But all that will change starting next year.
Because the federal health care overhaul prevents insurers from rejecting people with pre-existing conditions, programs like MCHA will no longer be necessary. People covered through MCHA will be able to enroll in commercial health plans through MNsure, the state's new online insurance exchange.
The Minnesota Department of Commerce, which regulates MCHA, plans to stop accepting new MCHA patients on Jan. 1, and end the program for good in 2015. However, those details won't be finalized until the end of this month, when the commerce department releases its plan to move MCHA participants to MNsure.
Whatever shape the plan takes, the state has a strong incentive to retire MCHA. The federal government would then kick in at least $55 million to subsidize coverage for MCHA's high risk, high cost patients.
MCHA ENROLLEES FRET ABOUT TRANSITION
But MCHA participants are worried about the change. They want to know if their current doctors will be included in the plans offered on MNsure. Some are concerned they'll lose access to the Mayo Clinic, a provider included in MCHA plans. And they're in the dark about drug, premium and deductible costs.
That information won't be publicly available until September at the earliest. Until then, people like Deborah Targ will be left guessing. Targ's MCHA plan has covered treatment for her bipolar disorder, and she credits her psychiatrist with helping her manage the condition.
"I have been very stable for several years now," said Targ, of St. Paul. "But [my psychiatrist] has been instrumental in keeping me that way. It would be very difficult if I had to go to a plan where I wasn't able ... to see her."
Other patients are worried that plans offered through MNsure won't cover the expensive drugs they need. That's a particular concern for those with multiple sclerosis who require specific treatments to keep the disease under control, said Daniel Johnson, Upper Midwest vice president of public policy and mission advancement for the National Multiple Sclerosis Society.
"Ultimately, this is an issue of both access and affordability," Johnson said.
As a result, the commerce department is mulling keeping particularly vulnerable patient groups, such as people will autism, in MCHA for a few more years. Commerce department officials are trying to figure out how to safeguard coverage for vulnerable patients without jeopardizing federal subsidies.
WILL RATES GO UP OR DOWN?
Another key question for MCHA enrollees is cost, said Anne O'Connor, spokeswoman for the commerce department. She's traveled the state with department officials gathering feedback about the program's transition.
Right now, MCHA premiums and deductibles span a wide range. A plan with a $500 deductible carries monthly premiums as high as $1,042. At the other end of the spectrum is a $10,000 deductible plan with monthly premiums as low as $110 for non-smokers.
But those rates are based on the cost of treating expensive medical conditions. Policies sold on MNsure can't be based on the customer's health status. Insurers can only take into account age, geography and smoking habits, so MNsure health plans will likely be cheaper for MCHA patients as a result, O'Connor said.
"That's a fact we're trying to make sure MCHA enrollees understand," she said. "That's a hard one [to believe] after you've been denied multiple times."
O'Connor also pointed out that those who don't qualify for a government program, such as Medical Assistance, may receive federal subsidies to offset the expense of paying for an exchange plan. But according to research by the University of Minnesota's State Health Access Data Assistance Center, the majority of MCHA enrollees make too much money to qualify for the help.
Tom Bloom, of Minneapolis, said buying coverage through MNsure will be a better deal for him and his wife. Bloom has been treated for a hernia and his wife has bone loss. They've been paying for a high-deductible MCHA plan for five years, with monthly premiums weighing in around $600.
"I was really grateful that we could get it because otherwise we wouldn't have insurance," he said. "But you end up paying [a lot] ... because you're in a pool with a bunch of sick people."
Bloom said that in five years, he's rarely used his plan.
It may seem counterintuitive that the state's high-risk pool includes people like the Blooms who have relatively minor conditions.
A lot of MCHA participants fit a similar profile, and they tend to be less expensive to cover, said Kirby Erickson, the MCHA's executive director.
On the flip side, the program includes a population of patients with significant health problems who use more health care than most, and are more expensive as a result, Erickson said.
Because of that, moving expensive MCHA enrollees to MNsure may jack up the cost for everyone else who buys a plan through the insurance marketplace.
A study commissioned by the state estimated that moving MCHA's high-risk patients to the exchange could increase costs for all MNsure participants by up to 19 percent.
But Elizabeth Lukanen, a senior fellow with the State Health Access Data Assistance Center who recently surveyed MCHA patients, said the reality may be much more benign than the projection. In part that's because the most common illnesses reported by participants are allergies, high blood pressure and high cholesterol -- conditions that are easily managed, she said.
"There absolutely is concern that this would be a really sick group of people flooding into the exchange," Lukanen said. "We just don't know for sure how this population is going to impact prices because we're not totally clear on how sick they are."
Erickson said the state will start encouraging the program's healthiest members to get coverage through the exchange starting on Oct. 1, when MNsure opens.
In the meantime, the state's commerce department is still trying to figure out how to ease the transition for MCHA's most-vulnerable enrollees.