Two events are bringing renewed attention to the future of the Affordable Care Act's (ACA) insurance protections for people with pre-existing medical conditions: a hearing in a legal case that would invalidate those protections and
In late August,
The Administration decided, however, not to defend the ACA in the suit from the state attorneys general that seeks to invalidate the law.(2) Instead, the Administration has urged the court to invalidate the law's core protections for people with pre-existing conditions. It also recently finalized federal rules that will expand short-term insurance plans that are exempt from ACA pre-existing condition protections, which will raise premiums for people seeking comprehensive coverage in the individual insurance market -- especially middle-income people with pre-existing conditions.(3)
In addition, congressional Republican leaders have repeatedly sought to pass legislation that would eliminate or greatly diminish the ACA's protections. And even a new
New Senate Bill Would Permit a Return to Harmful Insurer Practices
In the
The new
* Charge higher premiums based on non-health factors that can strongly correlate to health risk, such as gender and occupation;
* Charge older people far more, compared to younger people, than is currently permitted (most older people have pre-existing health conditions);
* Exclude coverage altogether for people's pre-existing medical conditions; and
* Revive "post-claims underwriting," in which insurers investigate the health histories of people enrolled in their plans, in order to classify health care services as related to a pre-existing condition and therefore not covered by the plan. If insurers can once again exclude coverage of pre-existing conditions, as S. 3388 would permit, they will have an incentive to comb through enrollee medical records and deny claims they can link (even tenuously) to a person's prior health conditions, tests, or symptoms -- particularly after enrollees receive very costly care.(5)
In most states, the bill likely would mean a return to pre-ACA insurer practices, such as women being charged more than men for the same health plan, people with pre-existing conditions being denied coverage of health care services that would be covered if they were healthier, and wide variance in protections depending on state law. Under S. 3388, a person with heart disease technically could purchase a plan (because insurers cannot deny them based on their illness), but then may find that, if they have a heart attack, the costs aren't covered because the medical event is related to a pre-existing health condition. Even people who do not know they have a pre-existing condition could face challenges to their claims from health insurers. In most states, prior to the ACA, a medical condition could be considered "pre-existing" and excluded from coverage even if it was not previously diagnosed or treated but merely produced symptoms that would cause an "ordinarily prudent" person to seek medical advice. And in several states, even conditions that didn't produce symptoms were considered pre-existing.(6)
Not only would a return of post-claims underwriting leave some people with overwhelming medical expenses, it would also inject new uncertainty for all enrollees in the individual market, as neither they nor their health care providers could be completely confident that their insurer would pay for medical services they need rather than deny their claims as related to a pre-existing condition.
Other Bills Seek to End or Weaken Pre-Existing Condition Protections
Meanwhile, the Administration continues to advocate for legislation proposed in the
The Cassidy-Graham bill(8) would have let states waive these protections for any insurance plan subsidized by the bill's block grant to states (which would replace the ACA's Medicaid expansion and marketplace subsidies, both of which would be repealed). A state that used even a small portion of its block grant funds to provide tiny subsidies to all individual market plans could then waive the ACA rules for its entire individual market. And, while insurers in these states would still be barred from denying coverage to people with pre-existing conditions, they could offer them plans with premiums of thousands or tens of thousands of dollars per month(9) -- a distinction without much of a difference for consumers.
Indeed, under the bill "most states" would ultimately modify their insurance-market rules, and "coverage for people with preexisting conditions would be much more expensive in some of those states than under current law," the
Support for Cassidy-Graham was strong enough that Senate Majority Leader
In addition, the ACA repeal bill that the House passed in
Furthermore, while ACA repeal legislation that the
Even as they worked to weaken pre-existing condition protections, various policymakers have sought to portray themselves as supporting those protections. In June, when the Administration said it would not defend the ACA's main pre-existing condition protections in the
But policymakers can't have it both ways: support for dismantling these protections in whole or in part is not compatible with support for "maintaining coverage for pre-existing conditions."
Footnotes:
(1)
(2)
(3)
(5)
(6) Claxton, op cit.
(7)
(8) H.R. 1628, https://www.cassidy.senate.gov/imo/media/doc/LYN17752.pdf.
(9)
(10)
(11) The joint statement is available at https://www.ahip.org/wp-content/uploads/2017/09/Joint-statement-AMA-AAFP-AHA-FAH-AHIP-BCBSA-9.23.17.pdf
(12)
(13)
(14)
(15) Center on Budget and Policy Priorities, "Senate Health Bill No Better Than House Version,"
(16) CBO, "H.R. 1628: Better Care Reconciliation Act of 2017," https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/52849-hr1628senate.pdf.
(17)
(18)
(19)
(20)
With Coverage Under Attack, Republican Ticket Is Against Preserving Care for Those With Pre-Existing Conditions
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