Clinical Geriatrics

Dr. Gambert is Chairman, Department of Medicine, and Physician-in-Chief, Sinai Hospital of Baltimore, and Professor of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

Although there are currently between 46 and 48 million persons in the United States without health insurance, and there is talk among the Presidential hopefuls of finding some solution to this growing crisis, an equally important crisis is the growing number of “uninsurable” Americans—even if one is willing to fund his/her own health insurance policy. The reality is that individuals with “preexisting conditions” are frequently denied health insurance, and this is a common practice in all but a minority of states that have legislation to prevent this from occurring.

Sure, there is the Consolidated Omnibus Budget Reconciliation Act (COBRA), a mechanism that allows persons who have been employed with health insurance to be able to continue this insurance at their own expense even after they leave or are involuntarily terminated from employment; one has to have had a policy in effect to be eligible for this plan. What most people are not aware of, however, is that this practice is only allowed to continue for 18 months, and the cost may be prohibitively expensive, as a recent employee I know just learned. (She is now facing the need to pay between $5000 and $10,000 annually, depending on the type of policy she chooses to continue.) Health Insurance Portability and Accountability Act (HIPAA) legislation allows another 18 months of continuation after COBRA coverage runs out if no other source of insurance has been able to be identified. However, for the person with a preexisting condition, the future after that is bleak.

Consider the married couple who has had one person employed for the past 35 years, with the other working as a homemaker. While the previously employed person who wishes to retire at age 65 can accept Medicare, his/her spouse, if younger, would not be eligible, and thus the couple would need to pay the high cost of COBRA coverage and then coverage under HIPAA until such time that the other person also becomes eligible for Medicare coverage. It is possible, however, that there might be years of inability to obtain any health insurance for the younger person, especially if he/she has some preexisting condition and has to wait until qualifying for Medicare.

The problem does not stop there, as not only may “identified” preexisting conditions lead to one being denied health insurance, but even the possibility that one might develop a problem from a genetic risk also may result in denial. When we are most vulnerable, we rarely have the ability to seek proper information, so whom do we turn to for advice? While insurance companies may vary in their policies, there is no universal guarantee of coverage, and the public remains vulnerable—especially the older population. We clearly need federal legislation to protect all Americans, whether we are fortunate and are healthy, or have the burden of some preexisting medical condition, whether it be hypertension, heart disease, breast cancer, or any other of the myriad of problems that are most certain to affect the majority of the aging population at some time in their lives. We also need to protect those who have a genetic predisposition to illness and remove the barrier of fear that many have of even getting tested, fearing the inability to obtain health and life insurance.