The Republican health care plan recently passed by the House would hollow out one of the most popular provisions of the Affordable Care Act: a prohibition on charging higher prices to people with pre-existing medical conditions. States, under the plan, could waive that rule, provided they offer publicly funded alternatives for coverage.
The Republican plan raises questions, including about cost: Many experts believe the more than $100 billion earmarked for alternative programs, such as “high-risk pools,” would be inadequate. According to the Congressional Budget Office, many patients with pre-existing conditions would be priced out of the market.
But the Republican proposal also raises a more basic issue: Who will decide what constitutes a pre-existing condition?
Before the Affordable Care Act, profit-taking insurers had lowered the bar for what was considered a pre-existing condition to include nearly every malady, making it difficult for many healthy patients to get affordable insurance.
I have interviewed many such people. Renée Martin was thrown into an unaffordable high-risk pool because of an abnormal Pap smear. Lisa Solod got turned away by four insurers because she was on thyroid replacement, an asthma inhaler and hormones — a not uncommon trifecta for women in their 50s. Wanda Wickizer was priced out of having insurance because she had taken Lexapro for depression. Jesse Albert found that he and his family were uninsurable because he had once had a benign skin cancer and a bout of hepatitis C, even though his immune system had cleared the virus.
Turning away people with just a hint of illness is a reasonable business strategy. But as so often occurs in the profit-oriented health system, what is best for business is not necessarily good for patients.
When the House Committee on Energy and Commerce studied insurance denials and exclusions for pre-existing conditions by the four largest for-profit insurers in 2010, it found plentiful evidence that “each company had business plans that relied on using pre-existing conditions to limit the amount of money paid for medical claims.” In documents reviewed by the committee, one company listed “improved pre-existing exclusion processes” as an opportunity to increase growth.
The committee report found that the insurance companies turned down one out of every seven applicants with pre-existing conditions. Such denials had jumped by nearly 50 percent between 2007 and 2009, as the apparently successful financial strategy gained sway.
In the pre-Affordable Care Act era, states that ran high-risk pools generally specified pre-existing conditions that automatically qualified patients for admittance — generally serious diseases like AIDS, diabetes or epilepsy. The determination was based on health, but patients who could show they had been turned down by insurers were also generally eligible. Insurers, with different motivations, draw very different boundaries. In interviews with Dr. Hall before the A.C.A., some Kansans said that merely having hay fever or being fat were enough to be placed in the pools.
Indeed, if insurers make the call about who to exclude, almost anyone who needs insurance would seem vulnerable. I’m by all measures really healthy but I, too, once had an abnormal Pap smear, have taken Lexapro for short periods of my adult life and very occasionally use an asthma inhaler before I exercise in winter. Since an orthopedist removed the cartilage in my right knee after a soccer injury in college (an operation that has since been deemed useless or harmful), odds are that I will someday need a knee replacement. Dr. Hall told me that surgery alone could throw me into a high-risk pool, by many insurers’ standards.
And what of the much-vaunted benefits of cancer screening? With the possibility of a poorly financed high-risk pool looming, a rational person might avoid a colonoscopy. A polyp removal might prevent cancer but could mean paying higher insurance rates, because patients who get polyps are at risk for developing more polyps, which can be precursors to cancer.
We all have — or will have — some kind of a problem in our medical history.
Today, Mr. Albert, 52, is not happy with the price of his family’s high-deductible Obamacare policy: $2,000 a month. Even so, he said: “The A.C.A. was a lifesaver for us. Everyone in my family has something that could be defined as a pre-existing condition. It’s expensive but I don’t have to worry about being excluded from insurance or about bankruptcy anymore.”