“Why I Do This” — A Blog Series
Before Any of It Existed
By Anne Glorioso, CEO · Solidarity Health Network, Inc. · Cleveland, Ohio
In 2001, I was called in by the Ohio Department of Job and Family Services to run seminars for dislocated workers. The occasion: the bankruptcy of LTV Steel, one of Cleveland’s largest employers. Thousands of steelworkers had just lost their jobs — and with them, their health coverage.
The seminars were scheduled for the week of Christmas.
I remember being stressed in a way that’s hard to fully describe. Several meetings per day, a room full of scared people, and a healthcare landscape that offered very few good answers. I was there to explain their options. The problem was that their options were not great.
When a Company Goes Bankrupt, COBRA Goes With It
Most people assume that when they lose a job, COBRA (the Consolidated Omnibus Budget Reconciliation Act — the federal law that allows workers to continue their employer’s health coverage after leaving a job) is a safety net. And usually it is.
Not when the employer is self-funded and files for bankruptcy. When that happens, the plan itself can collapse. COBRA requires a functioning plan to continue. There was no plan. So for thousands of LTV Steel workers, COBRA was literally off the table.
That left two options: enroll in a spouse’s plan, or buy individual health insurance.
Simple enough — except that many of these workers’ spouses didn’t work, or worked part-time, because the hours these steelworkers put in made it nearly impossible for a household to have two full-time earners. And individual health insurance in 2001 was a different animal entirely.
The Accordion
Before the ACA (Affordable Care Act), buying individual health insurance meant underwriting. Massive, invasive, painstaking underwriting. Every applicant had to complete a detailed health history application. And if you checked “yes” to anything — anything at all — there was a separate medical questionnaire for that condition.
- A DUI from twenty years ago? Questionnaire.
- An ear infection? Questionnaire.
- High blood pressure? Your doctor had to complete a form documenting your last three blood pressure readings.
I used to carry an accordion folder — the kind with more than 50 individual slots — just to keep all the different questionnaires organized so I wouldn’t have to call people back after the fact. When you’re enrolling thousands of individuals at once, you learn to be prepared for every possible “yes.”
Many people were rejected outright. Pre-existing conditions were not protected. Insurers could and did decline coverage based on health history, and there was nothing anyone could do about it. Those who were rejected had to go without coverage and hope for the best until a program for dislocated workers eventually came along.
And women faced an additional indignity that is almost unbelievable by today’s standards: pregnancy was not automatically covered under individual health plans. It had to be added as a rider — at significant additional cost — and you could not obtain the rider if you were already pregnant. Let that sink in for a moment.
The Man Who Stood on His Chair
I want to tell you about one moment I have never forgotten.
I walked into one of those LTV Steel seminars a few days before Christmas and began explaining the situation — the bankruptcy, the COBRA limitation, the underwriting process, the questionnaires, the very real possibility that some of them would be denied coverage entirely.
An older gentleman in the room — he was probably around my current age, though at the time he seemed elderly to me — stood up on his chair.
“All these years I have helped out others. I have donated money to people who needed it. I did everything right. I did everything in my power to protect my future. Where is my happy story? Where is my happy ending?”
The room was silent.
He was right. He had done everything right. He had worked hard, paid into the system, supported his community. And the system had no good answer for him. Not that week. Not that Christmas.
I think about him often. I don’t know what happened to him. But I have never walked into a meeting with a scared client and forgotten that there is a real human being on the other side of every file.
What the ACA Got Right — And What It Got Wrong
The Affordable Care Act, which passed in 2010, changed everything about the individual market. And while it has real and significant flaws — many of which have gotten larger in recent months — the single most important thing it did was eliminate medical underwriting for pre-existing conditions.
That alone was a revolution. What happened to those LTV Steel workers — being denied coverage because of a blood pressure reading, a past illness, a decades-old mistake — can no longer happen on the individual market. That is genuinely worth something, even on the days when the ACA feels like a regulatory obstacle course.
The other thing worth understanding — and this gets lost in a lot of the noise — is why premiums are so high and why individual mandate penalties matter. When there is no penalty for going without coverage, healthy people opt out. A 24-year-old who feels invincible looks at a health insurance premium and decides to spend the money on something else. That is completely rational behavior from where they sit.
The problem is that when only sick people enroll, premiums have to cover a much sicker population. Rates climb. More healthy people drop out. Rates climb further. This is called adverse selection, and it is not a theory — it is what happens every time a market loses its healthy enrollees. The individual mandate, imperfect as it was, existed to prevent exactly this cycle.
We now have a market with high premiums, limited plan options in many regions, and in some areas nothing but HMO (Health Maintenance Organization) plans with narrow networks. These are real problems. But the answer is not to go back to a world where a man with high blood pressure gets handed a questionnaire and told to wait while an underwriter decides whether he deserves coverage.
I was in that room. I know what that world looked like.
Why Any of This Still Matters
I tell this story not to relitigate a decade-old policy debate, but because context matters in this industry. If you want to understand why the rules are the way they are, you have to understand what they replaced.
Every regulation that feels burdensome today exists because something went wrong before it. Every protection that feels obvious now was hard-fought because someone, somewhere, stood on a chair and asked where their happy ending was.
At SHN, we have been navigating this landscape since before most of the current framework existed. We were here before Part D. Before Part C. Before the ACA. We remember what it looked like without them.
That history doesn’t make us nostalgic. It makes us very, very good at our jobs.
Anne Glorioso is the CEO of Solidarity Health Network, Inc., a full-service healthcare third-party administrator based in Cleveland, Ohio. SHN has been serving union funds, employers, and retiree populations since 1989.
www.shninc.org
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