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Friday, July 11, 2003 - Page updated at 12:00 AM

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More in state to flunk health-screening test

Seattle Times staff reporter

Grading your health


Starting Oct. 8, Washington residents who score 288 or higher on a state questionnaire grading their medical conditions will not be allowed to buy regular individual health insurance. Applicants are quizzed on 283 conditions. Major illnesses will automatically disqualify them. But even people who are not very sick could easily accumulate excess points. A sampling:

Dialysis: 1,000

HIV positive or AIDS: 800

Brain cancer: 750 (treated less than one year ago)

300 (treated between one and three years ago)

100 (treated more than three years ago)

Congestive heart failure: 600

Paralysis: 400

Pacemaker implant (complications): 300
(successful): 200

Major depression, without psychosis: 300 (treated less than one year ago)

200 (treated one to three years ago)

100 (treated more than three years ago)

Chronic back sprain or strain (more than four episodes): 250

Sleep apnea (if surgery is needed but not done): 250

Gall stones (if not removed): 160

Arthritis (excluding conditions controlled by aspirin or over-the-counter drugs): 150

Hyperactivity: 120

Bladder conditions: 110

Untreated cataracts: 100

Untreated hemorrhoids: 80

High blood pressure (not controlled by diet): 70

High cholesterol: 60

Source: Washington State Health

Insurance Pool

Gayle Hinchman failed Washington's health-screening test because of a benign cyst on her liver. And the Blaine resident is livid.

Hinchman is one of tens of thousands of residents required to take a 25-page questionnaire before they can buy health insurance. Anyone in the state who needs an individual policy — the self-employed, unemployed or employees without coverage at work — must take the test. But what many applicants don't know is that the test is designed to flunk roughly 8 percent of them as being too sick and too expensive to qualify for regular insurance.

Flunking can be costly: Those who don't qualify for private coverage can be forced into the state's high-risk insurance pool, where premiums can be as high as $970 a month, more than twice the regular rate.

Now, under a vote taken yesterday, the health test is about to become tougher to pass. Beginning Oct. 8, that will mean even more people like Hinchman — who are far from critically ill — won't make the grade.

For example, someone who suffers from both chronic back strain and high cholesterol will no longer be deemed fit enough to pass the test. Neither will a person with a bladder condition, gout and nose polyps.

The board of the Washington State Health Insurance Pool approved the scoring changes at a meeting yesterday in Seattle. The decision was needed to maintain compliance with a state law requiring that 8 percent of the sickest individuals be segregated into a more expensive high-risk pool.

Since 2000, Washington has permitted insurers to deny individual coverage to the sickest, or worst-risk, applicants. The rejected group by law must make up 8 percent of the entire individual insurance market. Yet only about 6.5 percent of the 75,000 Washingtonians who filled out the questionnaire last year failed it.

To meet the 8 percent target, the failing score will drop from 330 to 288 in October. (Sicker people receive higher scores.)

Allowing insurers to siphon the sickest people into the subsidized high-risk pool was part of a compromise that resurrected Washington's individual-insurance market in 2000. Insurers had stopped writing individual policies altogether after the state began requiring them to accept even the terminally ill for coverage. Premiums spiked, causing healthier people to drop their insurance and generating big losses for the insurers. Lawmakers eventually agreed to permit insurers to roll over the sickest applicants into the pool.

But some people with seemingly minor ailments are already finding it difficult to avoid racking up too many points. Even a combination of common medical problems — such as gallstones, high blood pressure and hemorrhoids — can send someone across the threshold.

That may surprise people who believe the high-risk pool is an insurer of last resort for cancer or AIDS patients and other seriously ill people.

Part of the challenge with the test is devising an acceptable way to adjust people's scores for the severity of their conditions. The test does that now in only a limited way. The questionnaire asks applicants whether they have any of 283 medical conditions, but not always how long they've had one or whether they have had it treated.

The test "is a very crude and rough tool," said Bob Crittenden, chief of family medicine at Harborview Medical Center, who represents consumers on the high-risk pool board. A thorough health assessment "requires a lot of questions and information. To do that, you would need a 100- or 200-page questionnaire."

Crittenden in the past has questioned whether Washington should legally allow insurers to reject the sickest applicants. At the least, Crittenden believes, the high-risk pool is failing as a safety net for those people because few can afford its high premiums.

Washington is one of 29 states with a high-risk health plan and the only one that specifies that a certain percentage of individual insurance buyers be separated into the pool.

Deborah Chollet, a health economist with Mathematica Policy Research in Washington, D.C., who has studied high-risk pools, said states can have viable individual insurance markets without artificially weeding out the sickest people. In fact, New York, New Jersey, Maine and Hawaii do not have high-risk pools yet still require insurers to sell policies to any individuals who want to buy, Chollet said.

Hinchman, of Blaine, argues that she's too healthy to be pushed into the high-risk pool. But when she applied for individual coverage with LifeWise, a health plan operated by Premera Blue Cross, she was told that she was disqualified because of her score of 654.

Hinchman's doctor had discovered a cyst on her liver about four years ago, but said it was harmless and advised her to leave it alone. So Hinchman checked yes to the question about whether she had a cyst involving a critical organ. That cost her 500 points, more than enough to disqualify her from buying regular coverage.

Ironically, if the cyst had been cancerous and had been removed, it would have cost Hinchman only 30 points.

Hinchman, a retiree who isn't old enough for Medicare coverage, has interim insurance that expires Nov. 30. She is upset that her only option may be to pay more than $700 a month to get coverage through the high-risk pool, compared to about $400 for LifeWise.

"There is nothing wrong with me. I'm as healthy as I can possibly be," Hinchman fumed. "I'm as angry as I have ever been. This is beyond comprehension for me."

James Reed, an actuary who helped to draft the health test's scoring system, said the penalty points for different conditions are tied to actual treatment costs. Thus a dialysis patient gets 1,000 points while someone with untreated cataracts gets 100 points. But as Hinchman's cyst example shows, the test sometimes falls far short in capturing a person's true health status, a point that Reed readily concedes.

Sometimes the sheer complexity of the questions leaves applicants stumped. Ineke Wolff, who with her husband runs a Renton company that takes scientific measurements, believes she was penalized by a flawed test.

When the couple and their son applied for coverage through LifeWise in June, Wolff's husband and son passed the health screen but she did not.

Wolff, 49, a former medical biller who is familiar with medical terms, suffers from a herniated disk. So she dutifully answered yes for "disk, herniated, ruptured or slipped." But she also marked the box for arthritis because, according to the explanation on the test, it included "degenerative disk disease." In addition, Wolff checked yes for radiculopathy, which she knew meant disease of the spinal nerve roots.

So Wolff's condition for which she believes the test unfairly penalized her three times added up to 250 points. Herniated disk by itself would have been worth 60.

Wolff, who has neck and arm pain from the herniated disk but otherwise calls herself healthy, appealed her initial total score of 550, which included other conditions. LifeWise knocked off 50 points but would not exclude arthritis, which carries 150 points. Bottom line: Wolff still can't buy coverage with LifeWise.

She is unsure what to do next. She does not want to enroll in a different health plan from her son and her husband, which would mean paying two separate sets of deductibles. And it would not make sense for the whole family to join the expensive high-risk pool.

She says she cannot understand how someone with a few aches and pains could be "judged the same as terminally ill people."

Wolff, who was born in the Netherlands, says that in a country as rich as the United States, people should be able to get affordable insurance.

"Holland has socialized medicine. Everyone has health care," she said. "Do we have to move to get health insurance? This is ridiculous."

Kyung Song: 206-464-2423 or ksong@seattletimes.com

On the Web

To link to the current Washington Standard Health Questionnaire and its scoring list, please see www.seattletimes.com

Copyright © 2003 The Seattle Times Company

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