A regular Source column, Undercurrents explores issues, ideas and events developing beneath the surface in the Virgin Islands community. This is the fifth and final in a set of stories examining health care services.
With a caveat here and there, the public perception of the Virgin Island’s health care system seems to be that it is, as Health Commissioner Michelle S. Davis rates it, good, overall. Perhaps even outstanding in some areas, though there is, as she also said, always room for improvement.
But if you can’t access the services, it really doesn’t matter how good they are.
A whole segment of the community is in that position. These are people who can’t afford to pay out of pocket, and who have no insurance coverage. They need an individual health care policy, and there are none offered in the Virgin Islands.
These are not people who elect to live without health insurance. Rather, these are people who want insurance but who aren’t covered by a group health insurance policy from an employer, who aren’t old enough to apply for Medicare, who earn more than the poverty-level eligibility for Medicaid, (even though Medicaid eligibility has been significantly expanded) and who have both feet planted firmly in the Virgin Islands so can’t sidestep into a plan available on the mainland by switching residency, as some others have done.
Just how many people fall into this category is uncertain. One longtime industry expert, insurance agent Steve Baker of Baker Magras and Associates, Inc., suggested it may be “less than 1,000.” However, a few months ago Dynel Soto, director of the Preferred Provider Organization known as V.I. Equicare, estimated the number at about 5,000. That was while Equicare was still negotiating – unsuccessfully – to get Triple S-Salud Inc. of Puerto Rico, doing business as Blue Cross/Blue Shield, to include individual coverage in its offerings. The company has since begun to pull out of the territory altogether.
The Powers that Be in the last and the current administration have been wrestling with the problem ever since the national Affordable Care Act –and the territory’s exclusion – inadvertently created it.
Last December, Lt. Gov. and Insurance Commissioner Osbert Potter said his office would soon propose an overhaul of the local system that would be a sort of Virgin Islands ACA and would deal with the issue of individual coverage, among other things.
But eight months later, there is still no plan and the sticking points making individual coverage problematic remain firmly in place.
For Baker, the solution boils down to just one thing: the Virgin Islands has to pass a law requiring everyone to have health insurance, just like the ACA. The so-called “individual mandate” of the national plan guarantees insurance companies a large pool of participants, both healthy and unhealthy, and goes hand-in-hand with the requirement that the companies must accept all applicants and not charge more for participants with pre-existing poor health conditions. That’s the “grand bargain” of ACA, he said.
On the local level, “No mandate means no individual coverage,” Baker said. It just doesn’t make business sense for an insurance company to offer coverage when it’s only customers may be bad risks.
The argument is not new to local government officials. Nor is it wasted on them. But they aren’t so sure the mandate is feasible.
“It is very, very necessary” to be able to offer coverage for individuals, said Sen. Kurt Vialet, chairman of the Legislature’s Committee on Health, Hospitals and Human Services. But requiring people to maintain insurance is “a double-edged sword” because some can’t afford it.
Potter voiced the same reluctance, saying he would hesitate to push for the mandate because of the flagging economy.
“We cannot make it mandatory,” said Gwen Brady, director of Banking and Insurance. The territory would have to have a large pool of carriers so policy-holders had a choice, and it doesn’t. The territory would also need to give companies incentives, like the federal government offers subsidies, but the V.I. government can’t afford to pay subsidies.
Equicare has not taken a position on mandates, Soto said. But like Brady, she said the government would have to put some things in place if it did make insurance mandatory, perhaps such things as tax credits for companies and penalties for non-compliance, with enforcement.
Potter and Brady said they are still trying to entice companies to offer individual coverage in the territory.
“I got some positive feedback from two companies,” Potter said.
“We’re asking them, ‘What would it take for you to come in,’” Brady said. While a mandate may not be in the offing, “We can look at underwriting.”
That is, at waiving the ACA requirement that insurance companies accept all applicants at the same premium rates, regardless of whether they are high risk.
Vialet said legislators have recommended to the administration and to the Government Employees Services Commission (which handles the government’s health insurance coverage for its employees) that it require the government provider – currently Cigna – to offer private individual coverage if it wants the government’s business.
Baker also suggested this approach.
But some observers are leery of such hardball tactics. John Harper, president of the V.I. Insurance Association called it “not healthy” and suggested it could drive companies away.
There’s agreement on one thing: The market in the territory is very small and that in itself is unattractive to a carrier. As Baker put it, the entire V.I. population is smaller than some single groups served by a large insurance company.
The Blue Cross pull-out is the most recent demonstration of the general vulnerability of the local market. The company stopped writing new policies as of August 1.
In a jurisdiction dominated by small businesses, it had been one of only two companies that were offering small group health policies (for fewer than 51members) so the impact is potentially devastating.
However, Potter said protections are in place.
“No one covered by their policy will be left uncovered,” he said. Blue Cross must honor existing policies until August 1, 2017, at which time most of them will have expired. It also is required to turn its portfolio over to another company (or companies.)
“We are currently engaging two additional carriers” to step into the small group market, he said.
He referred detailed questions to Brady, who said she could not put the names of the two companies on the record. But, she added, customers looking for insurance, can contact their agents.
“There is no problem there, no lack of capacity,” she said. In fact, her office is already working with a possible third company, one new to the market.