What Is a Pre-existing Condition?
The American Health Care Act (AHCA), aka “Trumpcare,” just passed the House of Representatives in hopes of repealing and replacing Obamacare. What is the controversy over pre-existing conditions? What is considered a pre-existing condition? And will you have to pay more for your plan if you have one?
Sanaz Majd, MD
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What Is a Pre-existing Condition?
The American Health Care Act (AHCA)
The American Health Care Act (AHCA)On May 4, 2017 the U.S. House of Representatives passed (with a 217 versus 213 vote) the revised American Health Care Act (AHCA), aka “Trumpcare,” in hopes of repealing and replacing Obama’s Affordable Care Act (ACA). If you are interested in the nitty gritty details of the new bill, here is the official link.
The greatest controversial concern of the new bill is the potential loss of protection against pre-existing conditions, one of the pillars of the ACA.
What is a pre-existing condition? Well, any health condition that a doctor has previously diagnosed you with prior to your health plan taking effect is considered “preexisting.” This could mean essentially anything, from a simple cold to an active cancer. Prior to Obamacare, it was common practice for insurance companies to refuse coverage for a person with certain preexisting conditions. And for other diagnoses deemed less costly, they may decide to cover you but to charge you more.
Currently under Obamacare, insurance plans cannot refuse coverage or charge you more if you have a prior health condition, aka a “pre-existing condition.”
Preexisting Conditions
Here are several of the top preexisting conditions according to Human Health Servicesopens PDF file in the non-elderly population (the same presumed population that will be purchasing in the exchange and most affected):
- Hypertension (high blood pressure)
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Behavioral Health Disorders (
depression,
anxiety,
bipolar disorder,
dementia,
alcohol/substance abuse disorders, etc.) - High Cholesterol
- Asthma or other chronic lung conditions
- Osteoarthritis
- Obesity
- Heart Disease or other heart conditions
- Diabetes
- Cancer
- Cerebrovascular disease (a common cause of stroke)
-
Infectious diseases (
UTI,
Pneumonia,
MRSA, etc.)
Under the new bill, the ACHA still forbids insurers to outright deny coverage for those with preexisting conditions as they did prior to Obamacare, but it allows the potential increase in premium costs for these people. This can occur only if the state you live in requests a waiver to opt out of the default protection. The state will be required to present a case to show evidence that it is overall beneficial to their state, and will also be required to create a high-risk pool in order to offset the increased costs for those people. If the plans are expensive, these patients may not be able to afford it any longer, rendering them uninsured once again.
So it all depends on where you live and what your particular state elects to do.
The Controversy with Gender Discrimination
Trumpcare has been criticized for discrimination against women as it will allow insurance companies to potentially use any preexisting condition to jack up premiums, even rape and domestic violence, as they did prior to Obamacare. Although nowhere in the actual bill does it specify any pre-existing conditions or diagnoses, let alone sexual assault and domestic violence. It will be up to the individual insurance plans to determine what conditions they will charge more for.
It will be up to the individual insurance plans to determine what conditions they will charge more for.
However, almost all states have banned the practice of referring to sexual assault and domestic violence as pre-existing conditions.
AHCA’s Preexisting Condition Summary
In summary, this means that, similar to the current Obamacare, patients with pre-existing conditions cannot be denied health insurance. However they can potentially be charged more. And the only way this can happen (assuming the Senate also approves the bill) is via a two-step process:
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The state you live in submits a waiver to opt out of the pre-existing protection and is able to prove that it will be cost-effective for their state. These states will then be required to set up high-risk pools to offset costs for the people of this pool.
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If the state waiver is approved, the insurance companies will be required to decide which pre-existing conditions they will charge more for and by how much.
AHCA is not law yet. It is now headed to the Senate as the next step. If all Democrats vote against it, the Republicans cannot afford to lose by more than 2 Republican votes in order to pass the bill. It will then be sent to the President for final signature.
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Please note that all content here is strictly for informational purposes only. This content does not substitute any medical advice, and does not replace any medical judgment or reasoning by your own personal health provider. Please always seek a licensed physician in your area regarding all health related questions and issues.
