This recent AARP article caught my attention last week. My father lost his kidneys in 2001 as a result of Wegener’s Granulomatosis, a rare autoimmune disease. In August, he was the recipient of a kidney generously donated by the family of a young man who had passed away. And this fall, for the first time in 11 years, he’s been able to go about his life without being tethered to a dialysis machine every evening. So I’m drawn to stories about kidney transplants, living donors, or families who choose to donate a deceased loved ones organs.
To sum it up, Radburn Royer is a healthy 57 year old who donated a kidney to his daughter four year ago, after her own had failed as a result of lupus. Prior to donating a kidney, Royer was covered by Blue Cross Blue Shield of Minn. It’s unclear what his health insurance status was in the interim, but last year he reapplied for coverage with them and 
was turned down. He’s appealed several times, but for now he’s covered by his state’s high risk pool (he has to pay $130 more per month for his coverage and has a higher deductible, both of which are common in high risk pools).
Individual health insurance in Colorado is underwritten just as it is in Minn., but underwriting guidelines usually vary from one state to another and from one carrier to another. So we contacted three of the top individual health insurance carriers in Colorado to see how they would underwrite an applicant who had previously donated a kidney. Cigna, Humana and Anthem Blue Cross Blue Shield all said that as long as the donor had been released from medical care and had normal blood pressure and blood lab results, the most likely underwriting outcome would be acceptance with a standard rate.
At first glance, this seems to be at odds with the situation experienced by Royer, but maybe it’s not. The AARP article notes that Royer underwent the rigorous health screening that is customary for all donors prior to surgery. You have to be in very good health in order to donate a kidney, and there’s little doubt that he was quite healthy at the time of the transplant. But although the remaining kidney takes over and continues to keep the donor very healthy in most cases, that doesn’t always happen. Some donors – despite very good health prior to donating – do end up with elevated creatinine levels, hypertension, and/or lower-than-optimal kidney function. According to the AARP article, BCBS of Minn. wasn’t able to comment on this specific case, but noted that “a person with one kidney who tests within normal ranges would be a strong candidate for coverage.” That sounds pretty similar to the underwriting guidelines of the individual carriers here in Colorado with whom we discussed this issue. The key is that the follow-up blood work has to be within normal ranges. For many donors, that is the case. But not for all of them. And unfortunately, creatinine levels that are above the normal range do generally indicate a problem with overall kidney function. Royer says that BCBS of Minn. rejected his application because of elevated creatinine levels in his blood. So it would appear that he might be one of the unlucky donors who experience problems with the remaining kidney.
The title of the AARP article is a bit misleading too. “Donate a kidney, lose health insurance” – Well, not really. Royer’s health insurance didn’t get cancelled as a result of the donation – he didn’t “lose” his coverage. The article doesn’t explain what – if any – health insurance coverage Royer had in the years following the transplant, but it was three years after the transplant that he applied for new coverage with BCBS of Minn. That is a very different situation than the picture painted by the title of the article.
Medical underwriting guidelines in the individual health insurance market are rarely popular (except for the fact that they are the primary reason that individual health insurance is so much less expensive than group health insurance). The provision in the ACA that requires all individual health insurance to be guaranteed issue starting in 2014 has been very well received, although the verdict is still out in terms of whether the individual mandate will be able to offset the price increase that would otherwise go along with a switch to guaranteed issue coverage. Nobody likes to think about being declined after submitting a health insurance application, and the idea seems especially onerous when the applicant has done something as altruistic as donating a kidney.
However, we do not yet have an individual health insurance mandate. And that means that medical underwriting guidelines are an essential part of the individual health insurance application process. Without them – and without the individual mandate starting in 2014 – there would be nothing to prevent people from applying for health insurance only when they needed medical care, and prices would be vastly higher than they are today.
So while I’m not impressed with the alarmist language AARP used in their title, I do see the content as a good reminder of the upsides to the ACA. Royer currently has health insurance through a high risk pool, and although many states had high risk pools prior to the ACA, some did not. All of them do now, thanks to the ACA. And although the individual mandate has been hotly contested over the past few years, it was upheld by SCOTUS last summer and will allow one of the most important provisions of the ACA – guaranteed issue individual health insurance – to become a reality in a little over a year.
In the context of kidney donation, it’s important that potential donors not be inadvertently scared off by AARP’s article. Kidney donors are heroes – anyone who had received a transplant will attest to that fact – and they save lives. The study that I linked to above followed donors for 20 – 37 years after their transplants. While some donors did end up having kidney problems, the majority had normal kidney function 20 – 37 years out from surgery, and would likely not have a problem obtaining individual health insurance, even prior to it being guaranteed issue in 2014. Most people who are healthy enough to be accepted as a donor will continue to be healthy after they donate a kidney.
