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Pre-Existing Conditions, High-Risk Pools, and Unicorn Saddles

By May 12, 2017November 24th, 2020No Comments
By Matt Kuntz, J.D.

Nine years ago, I moved away from practicing law to become the Executive Director for NAMI Montana. I had been advocating for improvements in the military’s mental health system since my stepbrother’s death the year before and a leadership role with NAMI Montana was the perfect opportunity to expand on that mission.  My knowledge of the overall healthcare system was limited, but it grew daily when responding to calls for help from families affect by mental illness across Montana.

One of Senator Max Baucus’s legislative staff met with me that summer to talk about the healthcare reform effort that was moving through Congress. No one knew whether Barack Obama or John McCain would win the presidency, but there was a general bipartisan agreement in Congress that something had to be done about America’s healthcare system. The two targets for improvement were people with pre-existing conditions who were being denied access to coverage and America’s working poor who did not receive coverage from their employers.

The staff member explained to me that the high-risk pool model of funding pre-existing condition had proven to be ineffective, so there were only two ways to address pre-existing conditions.  The first was some kind of single payer, or Medicare for All, program. The second was a mandate for everyone to buy private health insurance. The mandate model had been successfully piloted by Governor Mitt Romney in Massachusetts. Senator Baucus’ team had done prospective vote counts and realized that the mandate model was the only option that could pass the Senate at that time. They chose to address the second issue through the expansion of the existing Medicaid programs and by establishing health insurance exchanges for those who otherwise couldn’t access health insurance.

I’ve spent the following years trying to help Montana families navigate through the mental illness treatment system. It didn’t take me long to realize that the Senator’s staff member was right in that high-risk pools were about as valuable for the families I served as unicorn saddles. I was never able to get anyone into a high-risk pool. The rates were just too expensive. In hindsight, the failure of a concept comprised of putting all of the most expensive healthcare clients in the state into a small group insurance plan and then hoping that either the Legislature or Congress would effectively subsidize it to the point of being affordable was not surprising.

I also had to explain to people how America’s medical system as it was constructed at that time did not require, or even expect, most private insurance to cover people with pre-existing conditions: such as mental illness, back injuries, cancer, diabetes, etc. The system also did not have a solution for people who worked low-paying jobs and who could not afford healthcare coverage. Someone had to deliver that harsh news. I delivered it over and over again. I repeatedly counseled people about the medical bankruptcy process and how it was a built-in part of a healthcare system that had giant coverage chasms.

These hopeless calls slowly stopped coming in as the Affordable Care Act (ACA) took effect. The ACA wasn’t perfect, but it did make it so Montanans with existing medical conditions had legitimate options for healthcare coverage. Not surprisingly, I am deeply concerned about the move back to relying on high- risk pool unicorn saddles for people with pre-existing conditions. These are real people with real lives at stake.

I’m hopeful that this move will either stall or transition into a more realistic option. If it does not, then this version of healthcare reform will crash and burn. At that point, it will be almost inevitable that some form of single payer healthcare system will eventually be implemented by what will likely be a Democratic Congress elected by voters angered over the failed healthcare plan. The Republicans will then blame the Democrats for socializing medicine, but the true fault will lay on the backs of those in 2017 that tried to force through this iteration of healthcare reform legislation without a serious answer for how to care for American’s with pre-existing conditions.

​Matt Kuntz is the Executive Director of NAMI Montana. NAMI Montana is a grassroots organization that supports, educates and advocates for Montanans who live with mental illness and their families.

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