What Is A Pre-Existing Condition Anyway?

The Republicans claim no one with a pre-existing condition will be denied coverage in their newly passed House bill, the American Health Care Act (AHCA). But what is a pre-existing condition anyway, and why is everyone so worried about it?

When the Patient Protection and Affordable Care Act (PPACA, better known as Obamacare) was passed in 2010 and fully implemented in 2014, one of the provisions required that no health plan sold to individuals or groups could refuse to cover someone because of their “health status” (i.e. whether they had a medical condition that preceded enrolling in their insurance). By 2014 that was a national standard.

Before Obamacare, however, the patchwork of state and insurance regulations allowed each state to define pre-existing condition in its own way (See the Wikipedia description of how states regulated pre-ex before Obamacare). Not only did the list of these conditions vary by state, the maximum waiting period or “exclusion” period before you could get treatment for some these conditions also varied, from 6 months in Massachusetts to 10 years in Indiana. Before Obamacare, along with significant diseases that were considered to be pre-existing like cancer, diabetes and heart disease, there were a variety of fairly minor conditions:

According to the California-based advocacy group Consumer Watchdog , other possible situations falling under pre-existing condition clauses are chronic conditions as acne , hemorrhoids , toenail fungus , allergies , tonsillitis , and bunions , hazardous occupations such as police officer , stunt person , test pilot , circus worker , and firefighter , and pregnancy and/or the intention to adopt .[17]

The insurance market of the time was actually regulated on a state by state basis, meaning that you could be denied coverage for nine months in the state of Washington or an unlimited amount of time in Arizona. Doctors remember it as a terrifying time , many knowing patients who actually died for lack of coverage, contrary to what Rep. Raul Labrador said this weekend when he promised no one dies from lack of health care.

This is the way it was before Obamacare. And this is the way it would be under H.R. 1628 , the American Health Care Act, which now goes to the Senate for further consideration:

Retain private market rules, including requirement to guarantee issue coverage; prohibition on pre-existing condition exclusions, requirement to extend dependent coverage to age 26. Modify age rating limit to permit variation of 5:1, unless states adopt different ratios, effective 2018. Retain essential health benefits requirement, with state option to waive. Retain prohibition on health status rating with state option to waive for individual market applicants who have not maintained continuous coverage.

Sounds like the new bill would continue to include Obamacare prohibitions on pre-existing conditions, right? Actually, sort of. The actual language in the bill as amended says:

SEC. 137. CONSTRUCTIONS. 14 (a) NO GENDER RATING.—Nothing in this Act shall be construed as permitting health insurance issuers to discriminate in rates for health insurance coverage by gender. 17 (b) NO LIMITING ACCESS TO COVERAGE FOR INDIVIDUALS WITH PREEXISTING CONDITIONS.—Nothing in this Act shall be construed as permitting health insurance issuers to limit access to health coverage for individuals with preexisting conditions.

There is a huge amount of room for states to interpret this language. And while there is lots of technical and detailed language about how it would actually be implemented, probably the most important difference between the AHCA and the ACA is that insurers could charge MORE to cover people with pre-existing conditions if they have not had continuous coverage for at least 63 days in the past year. That isn’t such a long period of time. You might think you have coverage, but you forgot to pay a premium last month and then you got busy and forgot this month. OR, you found you couldn’t afford your premiums so you stopped paying. OR, you lost your job, thought you had COBRA but ended up without coverage for a few months. Under the AHCA, you could be charged a 30% penalty on your premium when you try to enroll, which could mean you would not be able to afford insurance at all. Tough luck, says the GOP. Some have even suggested that you shouldn’t have been sick anyway.

There is also a provision that allows states to redefine the ten Obamacare “essential benefits” by 2020, potentially dropping required services such as mental health, prescription drugs, maternity care from the list, and that could allow exclusions and increased premium costs. So the “guarantee” that no one will experience a rejection because of a pre-existing condition is not much of a guarantee at all.

One more thing. There have been a lot of rumors drifting around the net that rape would be considered a pre-existing condition. The bill does not specifically define pre-existing conditions, and domestic violence and rape definitely do not appear in the bill as specific excludable conditions. But, the bill would weaken protections and make some coverage unaffordable, and it gives insurers and states a lot more discretion about what they could cover or exclude. If you live in a state that wants you to continue to have access to the ten Essential Benefits and not penalize you if you haven’t been covered continuously, that’s good news for you. If not, Rep. Pittenger (R.NC) has a solution. He suggests you can move to another state if you want different coverage.

The ACA gave every American the same access to health insurance no matter what state they live in, and the guarantee you could never be denied insurance for any conditions you had prior to enrollment. The AHCA destroys that national guarantee, leaving us at the mercy of our state legislatures and the profit-motivated insurance companies. And THAT is something to worry about.