What pre-existing conditions might not the AHCA protect?

What pre-existing conditions might not the AHCA protect?
Posted at 1:48 PM, May 05, 2017
and last updated 2017-05-05 17:02:04-04

DENVER – Perhaps the biggest question most people have after the House on Thursday passed its version of the American Health Care Act is if they have a pre-existing condition, and if it will be covered under the new health care plan, should it pass.

Though the MacArthur amendment to the AHCA explicitly says that “nothing in [the AHCA] shall be construed as permitting health insurance issuers to limit access to health coverage for individuals with pre-existing conditions,” most medical organizations and opponents to the bill say that’s really not the case.

Instead, they say that pre-existing condition coverage will be limited by the House’s version of the bill, which would allow insurance companies to sell plans with higher deductibles and once again open up high-risk pools to cover people with pre-existing conditions, which the bill’s opponents say could lead to those people to being priced out of coverage.

Though there is no national standard for pre-existing conditions, as they are usually set by insurance companies, the number is vast. Some in Washington have said the AHCA will leave it up to the states to determine which pre-existing conditions might be covered.

The U.S. Department of Health and Human Services found in a January report that at least 61 million non-elderly Americans (23 percent of the population) have a pre-existing condition based on the narrow definition of them using state standards for high-risk pools before the Affordable Care Act was implemented.

But when HHS expanded that to a broader definition used by insurers before the ACA, that number ballooned to as many as 133 million non-elderly Americans – just over half the nation’s population under age 65, the age at which Medicare kicks in.

The report also found that about one-quarter of Americans with pre-existing conditions went without insurance for at least a month in 2014, and about one-third went without insurance for at least a month in 2013 and 2014. Lapses in coverage lead to penalties for Medicaid recipients and those trying to get pre-existing conditions covered under the AHCA as it currently stands.

“Any of these 133 million Americans could have been denied coverage, or offered coverage only at an exorbitant price, had they needed individual market health insurance before 2014 [when the ACA was implemented],” HHS wrote in its analysis.

It found that as states wound down high-risk pools and insurance companies prepared for the implementation of the ACA between 2010 and 2014, 3.6 million people with pre-existing conditions gained insurance. The uninsured rate for non-elderly Americans fell an additional 22 percent from 2014 through the first half of 2016.

So exactly what is a pre-existing condition?

The narrow definition, called the “objective definition,” included only conditions that a person received medical advice, a diagnosis, care or treatment for before they enrolled in a plan. That’s what Colorado used, according to analysis by the Kaiser Family Foundation.

Insurers were able to look back 12 months for pre-existing conditions and were able to exclude coverage for people for 12 months as well under the rules at the time. Some insurance companies would waive the exclusion period if a person hadn’t had a lapse in coverage or had the pre-existing condition covered before the lapse.

But some various insurance companies that operated in Colorado before the AHCA had more exclusions for people with pre-existing conditions on individual plans.

Per the Kaiser Family Foundation, this partial list of pre-existing conditions could be declined under the expanded definitions and were not covered before the ACA (there could be more):

  • Alcohol and drug abuse within a certain time period
  • Alzheimer’s/dementia
  • Arthritis, fibromyalgia, inflammatory joint diseases
  • Cancer within a certain time period
  • Cerebral palsy
  • Congestive heart failure
  • Coronary artery/heart disease, bypass surgery
  • Crohn’s disease/ulcerative colitis
  • Chronic obstructive pulmonary disease/emphysema
  • Diabetes mellitus
  • Epilepsy
  • Hemophilia
  • Hepatitis
  • Kidney disease/renal failure
  • Lupus
  • Mental disorders, including bipolar disorder and eating disorders
  • Multiple sclerosis
  • Muscular dystrophy
  • Obesity
  • Organ transplant
  • Paraplegia
  • Paralysis
  • Parkinson’s disease
  • Pending surgery or hospitalization
  • Pregnancy (current or expectant)
  • Pneumocystic pneumonia
  • Sleep apnea
  • Stroke
  • Transsexualism

In the January report, HHS found that people with hypertension, high cholesterol, behavioral health disorders, osteoarthritis and asthma or chronic lung disease pre-existing conditions were among those with the highest uninsured rates in the country in 2010. The percentage of those uninsured fell by 22 percent by 2014 with the ACA’s implementation.

For more estimates on how pre-existing condition coverage and Medicaid coverage in Colorado may be affected, click the links in this sentence.

The House narrowly voted to pass the AHCA on to the Senate on Thursday. But it is expected to draft its own version of the bill, which Sen. Cory Gardner, R-Colo., is part of the team working on it. Senate Majority Leader Mitch McConnell said the Senate would wait for the Congressional Budget Office to score the revised bill before it votes again.

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