‘People live in fear’ over pre-existing condition rules [The Kansas City Star, Mo.]

Mar. 16--You might say Dean Goering was scared to death.

He had known for months that something was wrong. The pain running through his leg was a lot like what he had experienced seven years ago when he was laid up in the hospital with a potentially lethal blood clot.

Goering had health insurance back then. And after years without coverage, he signed up recently with another health plan. He was just afraid to use it.

A paragraph in his new policy warned that he'd have to wait 12 months for coverage of a pre-existing condition.

Pre-existing condition. It's an insurance term that has become one of the scariest phrases in health care. For millions of Americans, these clauses make it virtually impossible to get their health problems covered.

Even the health insurance industry acknowledges that pre-existing conditions keep some people from getting into a health plan. Key provisions of the health care reform bills in Congress are aimed at getting rid of these exclusions.

With his history of blood clots, Goering, 50, was convinced he had a pre-existing condition.

So he never went to the hospital. He didn't see a doctor. Last month, when a blood clot likely shot up to his lung, there wasn't enough time for the ambulance to get him to an emergency room.

He died gasping for breath in his midtown apartment.

Goering's family and friends say they had pleaded with him to get help. But Goering didn't have much money. He had gone back to school to earn bachelor's and master's degrees and was living on savings. And he was someone who always paid his bills on time.

"He knew what he had when he had a swollen leg. He knew the dangers of a blood clot, that you could die from it," said his brother David Goering, a doctor at Lawrence Memorial Hospital.

"What's really devastating was he had the perception in his mind that if he went in to a doctor he would be denied coverage and he would be bankrupted. He knew insurance companies didn't cover pre-existing conditions."

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Pre-existing conditions are health problems you received medical attention for before you signed up for a health insurance plan. They can include obvious things like heart disease and cancer, but also such maladies as arthritis and asthma, even bunions and acne.

If you're on your own in the individual insurance market, health plans can charge you higher premiums, restrict the services they cover or turn you down completely for a pre-existing condition.

A national survey in 2005 by the Commonwealth Fund found that one in five working-age adults who tried buying individual health insurance over the previous three years was turned down or was charged higher premiums because of a pre-existing condition.

Group health plans, the kind employers offer, and the kind Goering got through the University of Missouri-Kansas City student health office, can't use pre-existing conditions to reject your application. But they can deny you coverage of a pre-existing condition for as long as a year.

So people in need of help may take a pass on medical attention as Goering did, health advocates say.

"We get many stories about people denied coverage for a pre-existing condition. And it's not at all unusual for people to avoid care out of the belief that this could happen to them," said Ron Pollack, executive director of Families USA, an advocacy group supporting health care reform.

"This is something the overwhelming majority of the population understands, and it's a practice that makes them angry," Pollack said.

But insurance companies can make some persuasive economic arguments for taking past medical conditions into account.

People with a history of illness are more likely to run up high medical bills in the future. And if pre-existing condition clauses weren't imposed, people would put off buying health insurance until they knew they were sick. That would be like homeowners trying to buy flood insurance after the rains start to fall.

"Our industry has proposed to make pre-existing conditions a thing of the past," said Robert Zirkelbach, press secretary for the trade association America's Health Insurance Plans.

"To make that work, everybody needs to participate in the health care system."

If everyone had health insurance all the time, the reasoning goes, costs and risks would be spread around so there would be no need for pre-existing condition exclusions.

That is the thinking behind the health reform bills in Congress: Pre-existing condition exclusions would be eliminated, but everyone would have to either enroll in a health insurance plan or pay a tax penalty.

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Dean Goering's girlfriend, Gail Patrick, says she knows what kept him from seeing a doctor:

"Money. He was looking at years and years of student loans."

Patrick is a nurse at Truman Medical Center. The job provides her with excellent health benefits, she said.

"If (Goering) had health insurance like I have health insurance, he would have gone to a doctor, most definitely."

Goering was an intense guy, Patrick said. Conscientious to a fault. He didn't smoke. He was in good health.

He dropped out of college when he was young. He worked for Federal Express for a time. Then he trained on computers and worked through a subcontractor for federal agencies. After he was laid off, Goering decided to go back to school.

Raised in a family of socially conscious Mennonites, Goering set his sights on a career in social work. He wanted to work for the Department of Veterans Affairs, helping veterans experiencing post-traumatic stress disorder.

"Our staff said he was the ideal intern," said Sheri Wood, executive director of the Kansas City Free Health Center, where Goering worked with a men's therapy group. "He went above and beyond with our patients."

For years, Goering lived frugally off savings as he went though the University of Central Missouri.

All he had to his name was an old car, some furniture, a computer and a modest retirement account.

After graduating from Central Missouri last year, Goering began work on a master's degree at UMKC.

Goering wasn't prone to health problems, Patrick said, except for one time about seven years ago when he was hospitalized for a few days with a painful blood clot in his leg.

That time in the hospital was covered. But his insurance plan balked at paying the bills.

"He had to fight and fight to get them to pay. That made a big impression," Patrick said.

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Goering started getting leg pains again last year.

Just before he graduated, he drove out to Central Missouri's campus in Warrensburg to visit the student health office, Patrick said.

"He did ask me one time what would happen if he had a blood clot," Patrick said. "I told him he could have a pulmonary embolism and he wouldn't be able to breathe."

Goering also called his brother, the Lawrence doctor, in September to tell him about pains in his leg and chest. His brother told him to have a doctor check it out.

"I don't have insurance. I could lose everything," Goering replied, according to his brother. At the very least, Goering worried that he would get sucked into the health care system and get lots of expensive tests he would have to pay for.

Goering debated whether to enroll in the student health insurance plan through UMKC. He read the 49-page policy. He called the insurance company several times to clarify the terms.

"He was just a stickler for details. He went through the policy with a fine-tooth comb," Patrick said.

"He was pretty convinced, right or wrong, that (his leg pain) was a pre-existing condition that would not be paid. He went on and on about that, based on the pages and pages of things they said they would or wouldn't cover."

Patrick told him the worst-case scenario would be bankruptcy if he couldn't pay his hospital bills. She asked him what he would do if the alternative was death.

"He never really answered that," she said. "The thought of going bankrupt was something he wouldn't consider. It was a blemish."

Just before the Feb. 12 enrollment deadline, Goering signed up for the student health plan.

Patrick continued to urge him to get help.

To mollify her, Goering went to UMKC's student health center on Feb. 20. Afterward, Goering and Patrick talked on the phone.

" 'Dean, did you tell them about your history?' I asked him," Patrick said. "He said, 'No.' I got so frustrated, so mad. I just went off on him. 'How could you be that irresponsible?' "

The next day, Patrick called him. She was worried and begged him to stay with her. Goering said he was too busy with schoolwork to talk.

But that night, Goering called her back. Patrick's cell phone was turned off, so she didn't retrieve the message until later. She keeps it still.

"Please call me, please call me," Goering said frantically, panting and gasping. "I'm having major problems. Please call me."

At the Health Care Access Clinic, a free clinic in Lawrence where he serves as medical director, David Goering sees many patients who, like his brother, have avoided getting care because they anticipated unpayable medical bills.

"Whether Dean made a bad decision or not, it was grounded in all this stuff about how insurance companies are denying payment for pre-existing conditions," he said. "Every day, people live in fear."

To reach Alan Bavley, call 816-234-4858 or send e-mail to [email protected].

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