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Posted September 29, 2009 | comments Leave a comment

Price of care: Woman's insurance costs soar after surgery

By James Heffernan -- jheffernan@nvdaily.com

FORT VALLEY -- When Niki Mason first noticed a swishing sound in one of her ears, she didn't think much of it. But as the noise level grew, so did her concerns.

In September 2007, Mason and her husband, Jim, went for a free thoracic screening at Rockingham Memorial Hospital. "I already knew that they were going to find something," she said.

They did. The swishing sound originated in one of her carotid arteries, the two large blood vessels on each side of the neck that carry oxygen to the front of the brain. If left unchecked, Mason was at risk of suffering a stroke.

The couple immediately scheduled an appointment with Dr. Irving L. Kron, a thoracic surgeon at the University of Virginia Medical Center. A series of tests revealed that Mason's artery was more than 90 percent blocked and closing fast. The body's circular flow of blood supplying oxygen to the brain was all that was keeping her alive.

For Mason, 62, an avid hiker and nature lover who doesn't smoke and considers herself exceedingly healthy, the diagnosis "was a little scary," she said.

Kron recommended a carotid endarterectomy to remove the blockage, and he successfully performed the procedure in November 2007.

"I have to hand it to [U.Va.]. They did a great job. They handled everything," her husband said, including the insurance claim. "Our policy held up, everything was fine, we paid our deductible and went on down the road."

Ensuing checkups confirmed that the damage had been repaired, and there were no complications. According to Mason, Kron believes that the narrowing of her artery was an anomaly, possibly brought on by scar tissue from an automobile accident.

But to the couple's insurance provider, Anthem Blue Cross Blue Shield of Virginia, Mason was damaged goods.

"Every year, they treat me like I've got some horrible disease because I have to go and get it checked," she said.

Self-employed, the Masons had watched their monthly premium increase ever since joining Anthem in 2002. Following her surgery, it swelled to $1,200.

"We're healthy people," her husband said, adding that they have only had one claim between them in more than six years. "We've been very proactive with our health -- plenty of exercise, good diet. ... Her cholesterol is below the threshold."

So last year the Masons began shopping around for a cheaper insurance provider.

"Every one of them accepted me because I have no health problems," he said. "Every one of them rejected Niki on the basis of her endarterectomy."

The couple said they were told by an Anthem representative that because of the procedure, their policy had been assigned to a separate risk pool, one that was closed to new members.

By law, insurers can't cancel a person's policy once he or she becomes a customer. But by establishing a new pool and roping it off, they can effectively rid themselves of certain individuals they consider to be high-risk, lowering the cost of insurance for their other customers.

In industry circles, the scenario is known as a "death spiral." It works like this: With each passing year, the closed group gets smaller, and its healthier members naturally opt out for less expensive coverage. Increasingly, people with high medical bills -- those who generally can't get health insurance elsewhere -- are trapped into paying steep premiums. The cycle continues until no one in the group can afford the policy, and the company eliminates it altogether.

"They have stopped enrolling people in our group, and the costs on those of us left in it are ratcheting up annually," Mason said.

Anthem officials would not comment for this story.

Insurance providers contend that closing pools of policyholders helps keep rates low and encourages people to buy health insurance.

The Masons now have separate plans from Anthem, each with a $5,000 deductible. They can afford the combined $900 monthly premiums, but they worry about those who are less fortunate.

"Can we afford our premium? Yes," Mason said. "Does that make me feel better when others can't? Absolutely not."

The couple believe that making health insurance available and affordable to all Americans should be a central piece in the health-care reform debate.

"This system of insuring people through employment is ridiculous," Mason said. "People change jobs, lose jobs, become unemployed all the time. Why should something as important and eternal as heath care be tied to something as ever-changing as a job?

"We don't do auto insurance like that. Why health care?"

The Masons believe a single-payer group, mandated by the government, would ensure everyone is covered, from cradle to grave, and keep costs low.

"We are all young. We are all old. We are all well, and we are all sick," Mason said.

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