Scott Svonkin joined the Los Angeles County Commission on Insurance 10 years ago because he was concerned about an emerging problem: people losing health coverage. Since then, the ranks of uninsured Americans have swelled to more than 46 million.
Svonkin almost became one of them.
It happened after he left a comfortable government job as a legislative chief of staff to start his own marketing and public affairs consulting business. Late last year he started shopping around for health insurance for himself, his expectant wife and his young daughter.
He knew he'd pay more without an employer picking up most of the tab. And he knew he'd have to fill out a medical questionnaire because, unlike job-based coverage, individual insurance in California is contingent on an applicant's health. But that didn't concern him because, he said, "I'm healthy as a horse, never smoked and have had no major surgery."
As it turned out, Svonkin was rejected by not just one but three of California's biggest health insurers, which cited his history of asthma, among other things.
"I couldn't buy it at any price," said Svonkin, 40, who lives in Sherman Oaks. "I remember thinking, 'This can't be happening to me.' "
Svonkin is part of what experts say is a largely hidden aspect of the nation's health insurance crisis: the uninsurables, people whom insurance companies won't touch, even though they can afford to pay high premiums. Some, such as Svonkin, pay steep rates for lean coverage from the state's high-risk insurance pool. Others simply go without.
Insurers have wide latitude to choose among applicants for individual coverage and set premiums based on medical conditions. Insurers say medical underwriting, as the selection process is known, is key to keeping premiums under control.
"Our goal is to extend affordable coverage to as many people as we can," said Cheryl Randolph, a spokeswoman for PacifiCare Health Systems Inc., a subsidiary of Minneapolis-based UnitedHealth Group Inc. "But because of the medical underwriting, we do not accept everybody."
Consumer advocates see the practice as cherry-picking -- a legal form of discrimination that is no longer tolerated in schools, public accommodations or workplaces -- and a way to guarantee profits.
"The idea is to avoid all risk," said Bryan Liang, executive director of the Institute of Health Law Studies at California Western School of Law in San Diego.
Jerry Flanagan, an advocate with the Foundation for Consumer and Taxpayer Rights, said it wouldn't take much to be left out of the private-insurance market. "A minor asthma condition or a surgery 10 years ago that requires no further medical care is enough to get you blacklisted forever," he said.
As a result, some people forgo treatment so as not to tarnish their health records. Others withhold information from doctors or ask them to leave details out of their records. For those who are uninsurable, healthcare often is the chief reason they stay in or take a certain job.
Claudine Swartz enjoyed running her own consulting business but had been rejected for individual insurance. After a scare over a benign cyst in her breast, the San Francisco resident closed her business and got a job with the University of California's health system, where she enjoys guaranteed coverage.
The episode made her realize that without insurance, she would have been on the hook for catastrophic expenses if her diagnosis had been more serious.
"I wasn't willing to take that risk," said Swartz, 35. "It's a real problem for people trying to be entrepreneurial and work on their own."
Uninsurable individuals pose a significant challenge for the state, which expects to spend more than $10 billion this year on people who lack adequate coverage.
Gov. Arnold Schwarzenegger, preparing to announce a proposal for expanding coverage in his State of the State address, has said he favors a mandate on individuals to buy health insurance -- just as drivers must carry auto insurance.
Democrats, who control the Legislature, have favored expansion of employment-based insurance and have signaled their opposition to a mandate on individuals.
Consumer advocates say such a mandate is unworkable unless insurers are required to sell coverage to all comers, as they are in several states, including New York and Massachusetts.
No one knows how many Californians are uninsurable. Blue Cross of California, which dominates the market, declined to disclose its rejection rate, as did its chief competitors. A 2004 industry survey found that health plans said they turned away about 12% of all applicants. But the rejection rate rose with age to 30% for people 59 and older.