NASHVILLE - It's not easy shopping for health insurance, whether you're in your 60s with a chronic condition or young, healthy and athletic.
On the one-year anniversary of the federal health care reform law, little has changed for thousands of adults who have to pay their own way.
Denial rates for individual health coverage remain high. Premium costs continue to rise. And there's uncertainty about the guarantees of universal coverage, due to start in 2014 but now facing renewed political and legal challenges in Tennessee and nationally.
Linda Pearce, of Nolensville, can't wait until 2014. She's paying $670 a month on a COBRA policy that will run its course before she's old enough to qualify for Medicare. COBRA is a federal law that allows displaced workers to stay on an ex-employer's health plan temporarily if they pay the entire premium.
"I had someone from AARP call me about insurance," she said. "I said something about pre-existing conditions. He said, 'Let me get back to you.' He never did."
Pearce is 63, takes medication for high blood pressure and has asthma.
While getting turned down may be expected for older people with health problems, insurers also are saying no to some young adults, and critics say some decisions are unfair.
Andrew Pass, 30, of Nashville, has given up trying to get insurance. He has been either denied or quoted premiums he can't afford.
His only ailments are attention deficit hyperactivity disorder, which he controls with medication, and minor complications from a work-related injury to his ankle two years ago. He grits his teeth and pays medical bills that average $170 a month instead of buying insurance.
"There's no way it makes sense for me to try to contemplate that," Pass said. "There are a lot of people out there like me. They are not looking for anything free or to beat the system."
Besides picking and choosing whom they insure, companies also can exclude ailments or injuries to specific areas of the body when they do offer a policy.
Lyrad Vass Gal was a healthy 27-year-old, self-employed physical therapist who played sports when she bought an individual policy from BlueCross BlueShield.
The insurer put a rider on any type of spinal condition or injury because she had once suffered from a bulging disk in her neck, she said. This amendment denied coverage for anything related to her spine.
The rider was on her mind every time she traveled in a vehicle.
"If I broke my back and severed my spinal cord, I would have probably been filing bankruptcy," Vass Gal said. She now has insurance coverage through her husband's employer.
UnitedHealthOne rejected Julie McReynolds, 31, of East Nashville, because she takes medication for irregular menstrual cycles. Having lost her job in March 2009, she started shopping for an individual policy because her COBRA eligibility had expired.
"I was absolutely panicked," McReynolds said. "Through my family history, I know how at a moment's notice your health can change. You can get in a car accident or something could happen."
McReynolds worked with an independent agent to get coverage through another company, Cigna, but pays a 20 percent markup on her premiums. She pays more because the irregular menstrual cycles are a symptom of polycystic ovary syndrome, which is caused by a hormone imbalance and adds to her risk for other diseases.
"Some companies will cover certain conditions," said Eric Jans, the agent who helped McReynolds. "Others won't."
Choices are limited
Consumers can count the number of dominant insurance companies in Tennessee on very few fingers. BlueCross BlueShield of Tennessee is far and away the top player, with other companies also in the market.
Most of the companies in Tennessee have denial rates that block roughly a third of customers from getting health coverage, according to the U.S. Department of Health and Human Services. The federal government began posting denial rates by state on HealthCare.gov in October.
BlueCross BlueShield of Tennessee had a denial rate of 34 percent.
UnitedHealthOne had rates that varied between 17 percent and 27 percent, depending upon the type of policy considered. Cigna's rate ranged between 24 percent and 40 percent. Humana's denial rate varied from 25 percent to 38 percent. Aetna showed a 32 percent rate.
Those rates are higher than the national norm.
A report issued in October by the U.S. House of Representatives Committee on Energy and Commerce determined that the nation's four largest for-profit health insurers denied one of every seven applicants because of a pre-existing condition. That translates into a denial rate of about 14 percent.
Insurers here also have hiked some premiums. Companies asked for and received approval from the Tennessee Department of Commerce and Insurance to increase premiums on 65 types of policies in the past year.
A national survey of 1,038 people who bought their own insurance, conducted by the Kaiser Family Foundation from late March through early April of last year, determined that 77 percent saw premium increases, with an average jump of 20 percent.
BlueCross BlueShield of Tennessee covers 63 percent of the commercial market in Chattanooga and 76 percent of the commercial market in Cleveland, Tenn., according to figures compiled by the American Medical Society's division of policy research.
The company's most recent premium increase was approved last month, hitting 22,937 PremierBlue policyholders with a 7.4 percent hike. That comes on the heels of an 8.9 percent increase approved in August 2009.
Mary Thompson-Danielson, manager for corporate communications at the Chattanooga-based BlueCross plan, said rates are going up because the population is getting older, using more medical services and because costs associated with prescriptions and new medical technologies are factors.
Thompson-Danielson also argues that the federal data on denial rates are misleading because they count a rider - a denial of coverage for a specific health condition - as an outright rejection. They also count markup on a policy because of a pre-existing condition as a denial.
"The way the data is presented is inaccurate and confusing for the consumer," she said.
Ellen Laden, the director for public relations for UnitedHealthOne, also questioned the government's numbers, noting that the percentages include people who didn't finish their applications.
By BlueCross BlueShield's count, its rejection rate decreased last year to 14.8 percent compared with 19.1 percent in 2009. UnitedHealthOne did not provide The Tennessean with comparable figures on denials when asked for such data.
Consumers face hurdles
Most Americans get insurance coverage through employer-sponsored plans - not individual policies - and that shields them from being more vulnerable.
Still, about one in four Tennesseans is at risk of being denied coverage because of a pre-existing condition, according to a report by Families USA, a consumer advocacy group.
Christi Malone, of Franklin, received a hard lesson about the rules governing pre-existing conditions when her husband lost a job.
"I was so surprised," she said. "We first applied with BlueCross BlueShield of Tennessee, who had been our provider through his company. They covered my doctor's appointments with these conditions. Then to turn around and say, 'Oh, you're private. We're not going to cover you because we don't have to.' I was very, very surprised."
Both Tennessee and the federal government sponsor insurance plans for people with pre-existing conditions, but those plans require people to go without coverage for three to six months before becoming eligible.
"You know what happens if [you] go without insurance?" Pearce said. "I'm going to need insurance."
Contact Tom Wilemon at email@example.com or 615-726-5961.