Washington – Pre-existing Conditions And The Health Plan: Who’s Covered?


    Demonstrators protest in front of the U.S. Capitol after the U.S. House of Representatives approved a bill on Thursday to repeal major parts of Obamacare and replace it with a Republican healthcare plan in Washington, U.S., May 4, 2017. REUTERS/Kevin Lamarque Washington – The Republican push to replace the Affordable Care Act was revived this week in Congress by a small change to their plan designed to combat concerns over coverage for those with pre-existing health problems.

    The change helped get the bill through the House of Representatives in a tight vote Thursday, but experts say it may make little difference in the hunt for affordable coverage for these patients.

    The bill proposes setting aside an additional $8 billion over five years to help states cover those who may be subject to higher insurance rates because they’ve had a lapse in coverage. That’s on top of about $100 billion over a decade for states to help people afford coverage and stabilize insurance markets.

    The problem, experts say, is that the money is unlikely to guarantee an affordable alternative for those who get coverage under a popular provision of the Affordable Care Act that prevents insurers from rejecting people or charging higher rates based on their health.

    “Many people with pre-existing conditions will have a hard time maintaining coverage because it just won’t be affordable,” said Larry Levitt, a health insurance expert with the Kaiser Family Foundation, which studies health care issues.

    The ultimate impact on those with pre-existing conditions remains unknown. The bill now heads for the Senate, where it is expected to change, and the plan leaves many important coverage decisions up to the states. Still, it is making some who are now covered by the Affordable Care Act nervous.

    John S. Williams, an attorney in New Orleans whose multiple sclerosis medication costs $70,000 a year, buys insurance through the Affordable Care Act’s marketplace. Without protections for pre-existing conditions he fears he would have to close his law practice and find a job with that offers a group insurance plan.

    “We always hear about job growth and business creation — being able to have affordable health care drives that,” Williams said. “I have tremendous satisfaction with owning a business, but I know that if I can’t get coverage, I would be forced to get a different job. I can’t not have coverage for my multiple sclerosis.”

    Here’s how coverage may change for those with pre-existing conditions under the plan:


    States will be able to get federal waivers allowing insurers to charge higher premiums to people with pre-existing illnesses who have let their coverage lapse. States can then use federal money to fund government-operated insurance programs for expensive patients called “high-risk pools.”


    Patients who couldn’t get or afford insurance could apply for coverage through these high risk pools, which existed before the Affordable Care Act was passed. Even though they were charged far higher rates, up to double the amount paid by consumers with no serious ailments, care for these patients is so expensive that government money was needed to fund the programs.


    In the more than 30 states that had high-risk pools, net losses piled up to more than $1.2 billion in 2011, the high point of the pools before the Affordable Care Act took full effect. Medical expenses outpaced premiums collected, and losses averaged $5,500 per person enrolled. States used fees and taxes to make up the difference, and states sometimes made it more difficult to some to qualify for care.


    An analysis by the health care consulting firm Avalere found that the money would only be enough to fund high-risk pools in a few small states. High-risk pools could fill up fast with patients who have a lapse in coverage.

    People with pre-existing conditions could lose their insurance if they can no longer work due to their health. The Republican health plan also is expected to raise premiums for older people, who are more likely to have a pre-existing condition.

    “This gets complicated fast,” Avalere President Dan Mendelson said.

    About 2.2 million people in the individual insurance market have some sort of pre-existing chronic condition, according to Avalere.


    Because the bill is expected to change, and because it leaves big decisions up to the states, it’s hard to say now what it would mean. Also, federal auditors have not had time to analyze the plan.

    Proponents of the bill note that people in poor health would still be protected as long as they maintain coverage. If they don’t, the higher premiums they are charged would revert back to standard rates after 12 months, assuming the customer could afford to keep paying.

    In the past, risk pools have not guaranteed coverage. States have established waiting lists to get into their risk pools or restricted admission to the pools, since they ultimately have to balance their budget and they have no way to predict how high costs will climb.

    “There is no guarantee in the law that people with pre-existing conditions would get access to affordable coverage,” said Kaiser’s Levitt.

    Adrienne Standley, the operations director at a start-up apparel business in Philadelphia, is not waiting to find out. Her plan through the Affordable Care Act covers treatment for her asthma and attention deficit disorder, but she’s afraid the Republican plan will mean she can no longer afford doctor’s visits and medication.

    “I’m looking at stockpiling, making sure I have an inhaler,” she said. “I’m pretty scared to lose coverage.”

    Follow VosIzNeias For Breaking News Updates


    1. Kupat Cholim, Italian health Insurance and Swiss Health system all provide more benefits. what will parents do with a child born with Down,’s syndrome

      • Huh kupat cholim as in Israel bituch leumi? Do you know that all the thearpy that our kids get barely exist in Israel? Under israel’s insurance you think every child that stutters gets speech, or a slow walker gets OT. Those therapists barely exist in Israel. The reason our insurance cost so much is because its so vast in its coverage.

      • This article does bring out a fundamental question. Lets leave aside the pre existing thing , will the exchange still exist? If not what about people that already signed up for the exchange?

        Also pre the ACA days, wasn’t it the case that someone who was already insured can switch insurance plans and that new plan cannot charge more for pre existing? (Not that I like that either) Assuming I am correct this attorney with MS should be able to get a new plan at the same price as others since he is not uninsured.

    2. I think everybody agrees that it is terrible to demand very high premiums from those with pre-existing conditions.
      The real issue is that many people think of insurance as something to be signed up for and used only when needed. If you get a serious diagnosis run and sign up on the spot.
      The above scenario is a recipe for failure of the system. Insurance companies would be bound to accept sick people, would have to raise rates and more people would only buy insurance when they are sick. This is referred to as a death spiral.

      Obama therefor insisted everybody get insurance.
      I expect they will make a rule that you can maintain insurance and pay the same as others if you do not lapse and reinsure because people playing that game are the problem.

    3. Commoditize health care in the same manner has we commoditize fire, police and sanitation. Oh we don’t commoditize those essential services, why are we still commoditizing health care (really chronic care) so that we can all take pills and shots. ACA, or any other alphabetic morass should be abolished in favor of creating a new essential service – health care.

      • Health care is far more complex and nuanced than fire and police departments. it requires a larger skill set too. In order to reach efficiency we need to commoditze it so that consumers can get the best product at the cheapest prices.

    4. Healthcare is not a commodity that can have a best product at the cheapest prices. It involves the Government, Hospitals, Doctors, Drug companies, Insurance Companies and Human Beings lives.
      Peoples lives and health matter . The insurance companies will only give you a product that gives them a profit . They do not care what happens if a person does not buy insurance . But elected official should care and ensure that everyone is covered.
      Most of the people and governments in this world understand this. The US Republican party does not understand this and does not care. All they care about is that you think that by throwing 20 million people off of healthcare, you will save a few dollars. Their job is done.What happens to those 20 million people afterwards ? If they don’t have insurance and they get cancer or diabetes or high blood pressure , they do not get treated. So they suffer and die.But you saved a few dollars on premiums – maybe.

      • True insurance companies are here to make a profit . But that’s where the benefit lies . Since government is not here to earn a profit they have no incentive to inovative or maximize efficiency . Thus under a government health system you end up with a less efficient plan with less coverage . This is most evident under the medicad program that lacks access to to Drs and is run inefficiently.

        Re your next argument , you claim that just because us struggling middle income earners want lower premuims deductibles and co pays is not a reason to cause 20 million Americans to be uninsured . Firstly , I think that 20 million is an exggaeration . Secondly , some of them will be forced to become less dependent on the govt and will just loose govt coverage but they will buy coverage else where . Lastly , I advocate making everyone even medicad recipients pay a poltury sum towards health care costs rather than getting everything from free shoes glasses and dental at no cost . They can pay what they pay for an iPhone . A little bit comes a long way . Once people have to pay even a 5$ copay for services they take care of their health . If everyone pays a little including the poor we can still insure those 20 million


    Please enter your comment!
    Please enter your name here