Who wants to go back to the not-so-distant past when people were denied health-care coverage, lost their coverage or had non-covered expenses because of a pre-existing condition? The 52 million non-elderly Americans with a condition on this list are as anxious for the return of pre-existing condition exclusions as the return of bubonic plague. Why should people with high blood pressure, diabetes, and even pregnant women have to worry about not having coverage for legitimate conditions? It is paradoxical and unwelcome.
The group of people most vulnerable to the current threat of pre-existing condition exclusions is people who purchase individual Affordable Care Act (ACA) marketplace plans, approximately seven percent of Americans. But even the 49 percent of Americans with employer coverage are not immune to the threat of repeal of ACA protections as Republicans continue their campaign to dismantle the ACA.
{mosads}Currently, because of the ACA, no individual plan can reject a person or charge more because of a pre-existing condition. No ACA plan can refuse to pay for essential benefits for any condition present before coverage started. Once enrolled, an ACA plan cannot rescind coverage or raise rates based solely on health status. Being female or pregnant is no longer considered a pre-existing condition that can result in being denied coverage or charged more. But all that could change.
Why the alarm about ACA protections for pre-existing conditions? The constellation of three actions has precipitated the threat. The late 2017 tax bill eliminated the ACA penalty for non-compliance with the individual mandate. Following this, Attorneys General from 20 states filed a federal lawsuit claiming the individual mandate is unconstitutional because of the 2017 tax reform law and therefore the entire ACA is unconstitutional. The logic goes if the ACA is unconstitutional so are protections regarding pre-existing conditions. This alone did not garner much attention. However when the Trump administration refused to defend the ACA as the law of the land in the federal lawsuit, the little-discussed lawsuit gained traction.
The stated goals of the ACA are to make health care more accessible and affordable. One way the ACA does this is through broad risk pools where low-risk, healthy individuals subsidize high-risk individuals. Without the ACA individual mandate, guaranteed issue of coverage, essential benefits and adjusted community-rated premiums, low-risk individuals would not participate in the same plans as high-risk individuals and the risk pool narrows or becomes segmented.
In addition to the stark partisan divide on the ACA, there is a growing gap between the rhetoric and actions of federal politicians and the American public. Following four failed efforts to repeal and/or replace the ACA in 2017, public support was strong for improving, not dismantling, the ACA. In August 2017, 60 percent of Americans polled were pleased that Congress failed to repeal or replace the ACA. A large public majority also favored Republicans in Congress working with Democrats to improve the ACA.
More recently, 76 percent of survey respondents support continuing ACA provisions prohibiting insurance companies from denying coverage because of pre-exiting condition; this includes 88 percent of Democrats, 77 percent of Independents and 58 percent of Republicans. Similarly 72 percent of respondents support not charging sick people higher premiums, another ACA consumer protection currently in place. The issue is personal with 57 percent of respondents saying they or someone in their home has a preexisting condition.
If you have employer-based coverage, you may not be as protected as you think. Before the ACA, employer plans could not deny coverage or charge more because of pre-existing conditions. But they could exclude coverage for pre-existing conditions for up to year and this is a problem for someone with a pre-existing condition. It is also a problem if you leave your job, experience a life change such as divorce or retirement and cannot secure a plan with protections.
Ten Republican Senators have filed a bill called the Ensuring Coverage for Patients with Pre-Existing Condition Act. The bill does preserve access to health-care coverage but permits denial of expenses for a pre-existing condition. Read the fine print and be wary of midterm election hype. You should make sure your elected officials and candidates hear from you about how policy decisions impact people back home in the district. Voting is not optional.
Carole R. Myers, R.N., is a senior fellow with the George Washington University Center for health policy and media engagement and an associate professor at the University of Tennessee College of Nursing and Department of Public Health.