Health Risk Pool (n) groups of people who share common health vulnerabilities; insurance classifications of disease processes which can be classified according to the degree of risk that the insurance company will face a loss of payments-to-premiums ratio
(Satire Alert: for stealing fire to give to humans, Prometheus received a punishment from the gods: to be chained to a rock while vultures plucked out his liver every day, only to have his liver grow back)
Health risk pools are at the core of the Affordable Care Act, and the derailed American Health Care Act, debate. The ACA’s approached the issue by requiring everyone to have “Essential Health Benefits” * covered. The AHCA wanted to change this by revoking the federal mandate while empowering each state to determine what benefits it considered essential for its citizens.
A few years back, the president of the hospital where I previously worked came to a staff meeting and asked, “What could make your job more enjoyable?” A co-worked wryly replied, “A coffee stand and healthy patients”.
Beyond the appearance of AHCA allowing for regional differences, the two plans approach health risk pools differently. ACA required that everyone pay for the essentials, even when some essential services would never be used by a particular individual. AHCA wanted to get to al al-a-cart approach, in which some services could be eliminated according to individual state legislative decisions.
“Maternity and newborn care” is one area contested by ACA and AHCA supporters. I do not know many men who will need maternity care, but all men were required by ACA to pay toward the expense of women bearing and caring for newborns. Maybe you could argue that few women conceive children without a man somehow involved. This spreads out the cost. Many AHCA supporters want states to have the right to eliminate maternity care because they believe this is an intrusion into family decisions and autonomy (I will not even go into the anti-abortion implications, as eliminating maternity care also eliminates abortion coverage, which many AHCA supporters agree with).
In a news interview on NPR, one of the Freedom Caucus members stated that the purpose of AHCA was to eliminate health risk pools from those services that would need to be covered. This would reduce the premium rates, which is a primary objective of the Freedom Caucus.
Consider the logic: paying for pre-natal care, births, and newborn care cost money. If we eliminate this as a benefit, we can keep premiums down for everyone. Women, and hopefully their spouses, should plan for children, including having enough money to pay for their pre-natal care, births, and newborn care. Don’t saddle society with that expense.
Let’s take this to it’s illogical conclusion. Let’s start eliminating some other costly health risk pools.
Diabetes and Obesity Health Risk Pool: these folks are destined to expensive procedures like daily glucose monitoring, insulin injections, cardio-vascular problems, dialysis, amputations, etc. As Type II Diabetes and obesity are mostly related to decades of lifestyle choices, let’s eliminate this health risk pool. The sooner they die (only takes about seven days without dialysis) the less our premiums will cost.
Cardiovascular Health Risk Pool: If everyone filled out a Do Not Resuscitate order ahead of time, we could avoid unnecessary emergency room visits, cardiac catheterization, heart value replacements, open heart surgeries, stroke rehab, etc. That will keep our premiums down.
Cancer Health Risk Pool: If Baby Boomers do not follow The Who’s advice, “I want to die before I get old”, they will likely get cancer eventually. Surgery, radiation, chemo and all those MRI’s cost lots. Eliminating cancer care would reduce our premiums.
Dementia Health Risk Pool: If cancer does not do someone in, they are likely to live long enough for cognitive decline to set in. There are several variants: Alzheimer’s Dementia, Leui Body Dementia, Parkinson’s Dementia, Multi-Vascular Dementia. The process is essentially the same in that some region of the brain, which govern’s memory, information process, and organizational skills loses neurons. When enough circuits give out, the same result occurs as happened to my 15-year-old stereo-receiver, which we replaced recently. Lots of research is going into how to cure and curb the end result of dementia. Eliminate this as a risk pool, and we can bring down the cost of insurance.
Orthopedic Health Risk Pool: Broken bones to arthritic joints result in a lot of surgeries and rehab. Most of these occur from lifestyle decisions (athletes wearing out joint surfaces through too much activity) and risky behavior (going outside to slip on ice). Why should everyone pay for someone else’s joint replacements and rehab? Eliminate orthopedic procedures to keep health premiums down.
Okay, you probably have my point here. If you want inexpensive health care premiums, plan to pay for various procedures separately from what will be covered by your plan.
Some years ago, when the issue was freedom of motorcycle enthusiasts to ride without helmets was a topic, I suggested we should legislate a Buzzard-Bill. Essentially, anyone could ride a motorcycle without head protection, as long as he or she signed a waiver for emergency services. In essence, you cane take a risk as long as you do not obligate someone else to rescue you from the potential consequences. We could do the same to keep health care premiums down. Opt out from certain health risk pool coverage, and well leave you in the ditch on the side of the road.
But, what is the purpose of insurance? Is insurance not a social contract in which a group of people commit to set aside a designated amount of money periodically to pay for expenses related to the group’s agreed upon concerns (whether health care, automobile collisions, house fires or floods, travels cancellations, etc.)? If that insurance does not cover most of what people might need at some point, who benefits from the premiums?
The main point of ACA was to bring everyone into t he process of taking care of all of us for a minimum range of essential health benefits. Why had the private sector not developed a health care insurance system already, such that the government did not need to step in? Is the point of capitalism only to make money, or is it to meet the needs of society?
We do have a nice coffee bar in the hospital, now.
* Essential Health Benefits: ten benefit categories: (1) ambulatory patient services; (2) emergency services; (3) hospitalization; (4) maternity and newborn care; (5) mental health and substance use disorder services including behavioral health treatment; (6) prescription drugs; (7) rehabilitative and habilitative services and devices; (8) laboratory services; (9) preventive and wellness services and chronic disease management; and (10) pediatric services, including oral and vision care