Genetic discrimination in health insurance: current legal protections and industry practices.

Most states have enacted genetic nondiscrimination laws in health insurance, and federal legislation is pending in Congress. Scientists worry fear of discrimination discourages some patients from participating in clinical trials and hampers important medical research. This paper describes a study of medical underwriting practices in the individual health insurance market related to genetic information. Underwriters from 23 companies participated in a survey that asked them to underwrite four pairs of hypothetical applicants for health insurance. One person in each pair had received a positive genetic test result indicating increased risk of a future health condition--breast cancer, hemochromatosis, or heart disease--for a total of 92 underwriting decisions on applications involving genetic information. In seven of these 92 applications, underwriters said they would deny coverage, place a surcharge on premiums,or limit covered benefits based on an applicant's genetic information.

Association health plans: what's all the fuss about?

Policymakers have tried to address the problem of the uninsured and to help small businesses with rising premiums by encouraging associations to offer coverage. Although supporters and opponents have made claims about the potential impact of this strategy, the association market has not been studied in depth. Examining current standards might explain why proponents seek changes. This paper discusses states' approaches to regulating health insurance offered by associations, including "self-insurance," as well as existing state exemptions from state insurance laws that otherwise would apply to coverage sold to small businesses, self-employed people, and individual purchasers. We also examine market problems such as insolvency and fraud.

Federal aid to state high-risk pools: promoting health insurance coverage or providing fiscal relief?

To help people whose health conditions make it difficult for them to obtain insurance coverage, the Trade Act of 2002 initiated federal matching payments to support state high-risk pools and promote coverage expansion through them. Some 30 states already had high-risk pools, but enrollment was very limited, largely because of high premiums, exclusion of coverage for preexisting conditions, and high cost-sharing. In interviewing officials from high-risk pools that received grants in the program's first year, the authors found that most states did not use grant funds to make their pools more accessible or affordable; instead, 18 of 19 states used some or all funds to refinance existing programs. Only one state used its entire grant award to reduce enrollee premiums, expand covered benefits, or otherwise enact changes to promote enrollment. Policymakers may need to strengthen grant requirements and/or financial incentives to promote expansion of coverage via state high-risk pools.

Ensuring health security: is the individual market ready for prime time?

Proposals to expand coverage of the uninsured through federal tax credits rely heavily on the individual insurance market. Yet the current market makes coverage less accessible, less affordable, and inadequate to meet the needs of many people without insurance, especially those who have modest incomes or are in less-than-perfect health. States' efforts to regulate the individual market can improve access for the vulnerable but, absent subsidies, may place coverage out of reach for the young and healthy. A combination of subsidies and market reforms could make insurance available to millions of Americans.