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Pre-Existing Conditions No Longer an Obstacle to Care

By Dr. Mona Mangat

Have you read about the case of Christina Turner? Let me recap: she fears that she was raped after being slipped a knockout drug and awakening on the side of the road with injuries suggestive of a sexual assault. She seeks medical advice and is put on 30 days of anti-HIV medications. Soon after, Christina loses her health insurance and as she attempts to obtain new coverage she is now deemed to have a ‘pre-existing condition’ and is uninsurable.

Not all stories are as dramatic, but they all illustrate the malicious attempts by insurance companies to avoid responsibility for their enrollees. In my private allergy/immunology practice, I cannot count on my two hands the number of patients that have exclusions in their insurance policy for the very condition they are seeing me for. I recently saw an 8yr old child with severe persistent asthma. She was insured through her Mom until Mom lost her job with a financial services company 2 yrs ago. The family struggled financially and went uninsured for almost 11months. Thankfully, Mom got another good job that offered her family health insurance, but now my patient has a pre-existing condition- her asthma. She needs allergen immunotherapy, expensive controller medications and close monitoring of her asthma symptoms. She has been on the verge of hospitalization several times and will likely end up hospitalized for her asthma. The family comes into the office sparingly, when there is no other alternative, as the cost will not be covered by her insurance policy. On top of the stress of unemployment, did they even have any idea that a pre-existing condition clause was looming overhead? Probably not.

It is fair to say that the purpose of the pre-existing condition clause was never intended to simply deny benefits to sick people. The goal was: protect the insurance companies from people who would not carry coverage until they became ill, and then tried to obtain coverage illegally by lying on the application. But somehow this relatively reasonable clause has provided justification for some of the most egregious acts committed by insurance companies. Today there are insurance plans that consider having given birth via a cesarean section a pre-existing condition. Did you know you might have a pre-existing condition if you are the victim of domestic violence, or have been pregnant? – so in essence, being a woman- a pre-existing condition.

Many opponents of health care reform and insurance regulation claim that this insurance practice is quite rare. In fact, in 2009 HHS released a report called ‘Coverage Denied: How the Current Health Insurance System Leaves Millions Behind’. This data reveals that approximately 36 percent of those who tried to obtain insurance directly from companies in the individual insurance market – were denied coverage during the last three years, charged higher premiums or refused coverage for a pre-existing condition.

Other opponents of the PPACA state that doing away with the pre-existing condition clause will ensure the fiscal demise of insurance companies. They also warn that, in return, insurance companies will raise premiums leading to federally mandated price caps and further government regulation of the insurance sector. This issue has been considered, and is a large part of why we will have an individual mandate requiring most people to obtain health insurance. As Ezra Klein stated:

‘The theory behind the mandate is simple: It's there to protect against an insurance death spiral. Now that insurers can't discriminate based on preexisting conditions, it would be entirely possible for people to forgo insurance until, well, they develop a medical condition. In that world, the bulk of the people buying insurance on the exchanges are sick, and that makes the average premiums terrifically expensive. The mandate is there to bring healthy people into the pool, which keeps average costs down and also ensures that people aren't riding free on the system by letting society pay when they get hit by a bus’

I must confess, I don’t really care if insurance companies post 10% or 20% less profit in the coming years. What I care about is that my patients, family members, friends and neighbors don’t have to worry that, in the event of an illness, they won’t be able to count on their insurance companies to honor their part of the agreement.

As of today, insurers will no longer be able to exclude children with pre-existing conditions from being covered by their family policy. For current policies, that means insurers will have to rescind pre-existing condition exclusions. The same will not occur for adults until January 1, 2014. In the interim, on July 1, 2010 PCIP was launched- the Pre-Existing  Condition Insurance Plan to insure those who have been uninsured for the past 6 months due to a pre-existing condition. This was to be administered on a state level and we’ve seen many states relinquish control to the federal government.

So on this 6 month anniversary of the passage of the PPACA, we can all breath a little easier knowing that being born with a congenital malformation or having cancer or being physically abused cannot be used as grounds for being uninsurable.

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