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As the 2018 midterm elections draw near, healthcare takes center stage for voters, with a key focus on maintaining protections for individuals with pre-existing conditions.
As a result, politicians are eager to declare their support for coverage for those with pre-existing conditions, a cornerstone of the Affordable Care Act that many argue was a major factor in preventing its repeal by Republicans last year (it's considered the most popular element of the law).
With both Democrats and Republicans asserting that they are the party best positioned to safeguard health insurance coverage for the most vulnerable, who can you trust?
What Exactly Are Pre-Existing Conditions?
Pre-existing conditions refer to any illness, disease, or chronic health issue a person has before or during their attempt to purchase insurance. For this discussion, we are focused on acquiring coverage in the individual insurance market (not through an employer), a process that the Affordable Care Act significantly reformed.
Historically, insurers would use any existing illness or disease to either deny coverage or sharply raise premiums. According to the Kaiser Family Foundation, fifty-two million adults under 65, or 27% of that population, “have pre-existing health conditions that would likely make them uninsurable if they applied for health coverage under medical underwriting practices that existed in most states before insurance regulation changes made by the Affordable Care Act,” and this is a conservative estimate.
This applies not only to conditions such as cancer and diabetes, which could make you ineligible for coverage or increase your premiums, but also includes conditions like:
Acid Reflux (higher premiums)
Acne (higher premiums)
Asthma (higher premiums)
Epilepsy (denied coverage)
C-Section (higher premiums)
Celiac Disease (higher premiums)
Heart Disease (denied coverage)
High Cholesterol (higher premiums)
Kidney Stones (higher premiums)
Knee Surgery (higher premiums)
Mental Disorders (e.g., bipolar disorder, eating disorders) (denied coverage)
Migraines (higher premiums)
Pregnancy (denied coverage)
Seizures (higher premiums)
Stroke (denied coverage)
Sleep Apnea (denied coverage)
Transsexualism (denied coverage)
Ulcers (higher premiums)
Certain medications and jobs—such as law enforcement, security guard, or taxi driver positions—were also grounds for denying coverage. (You can see what insurers were looking for on this old application.)
As a result, many individuals went without coverage—KFF estimates 18 percent of individual market applicants were denied pre-ACA, which is considered a conservative estimate since many with pre-existing conditions didn’t even attempt to apply. According to a Center for American Progress report, “Insurers quoted premiums as much as 50 percent higher for depression and 100 percent higher for breast cancer.” Additionally, one underwriting manual indicated that being overweight could lead to a 25 percent increase in premiums for some plans.
The report also indicates that even individuals with “mild” conditions would be required to pay thousands more for coverage than those without health issues.
For example, an individual with asthma would be charged 106 percent more than a healthy 40-year-old, leading to a premium surcharge of $4,340. For diabetes, the surcharge would amount to $5,600 per year. For those needing extensive care, premiums could become unaffordable: Pregnant individuals would face a $17,320 premium increase, those with rheumatoid arthritis or other autoimmune conditions would pay an additional $26,580, and individuals with metastatic cancer would be charged an extra $142,650.
The ACA Ensured Protections for Pre-Existing Conditions
Prior to the ACA, insurers in the individual market could deny coverage to those with pre-existing conditions, exclude coverage for those conditions, or inflate prices so high that individuals couldn't afford the insurance. The ACA, which took effect mainly in 2010 and 2011, prohibited these practices and banned discriminatory pricing based on age and gender (older individuals and women were frequently charged more than younger and male applicants).
Employer-based health insurance is primarily regulated by ERISA rather than the ACA, meaning that large employers cannot deny coverage based on an employee’s health history. However, certain provisions of the ACA still apply to employer-provided plans, such as a specific aspect of pre-existing conditions coverage, which we wrote about before:
Prior to the ACA, employer health plans couldn’t refuse coverage or increase your premiums, but they could exclude coverage for pre-existing conditions for up to one year if you failed to maintain continuous insurance coverage. This is the scenario that would return if the ACA’s protections were repealed. (Both large and small group plans would face even worse consequences.)
Although it’s possible that a new law could be enacted to protect coverage for individuals with pre-existing conditions if the ACA is repealed, doing so would effectively return the American healthcare system to its pre-2010 state: Denial of coverage, astronomical premiums for people with a history of illness, higher costs for women, and more.
20 Republican-Led States Are Suing to Overturn the ACA
Currently, 20 states governed by Republican legislatures are suing the federal government in an attempt to end the ACA, with a particular focus on dismantling protections for pre-existing conditions (likely spurred by a prior successful challenge to the law’s individual mandate). The Trump administration has opted not to defend the law in court. If they succeed, “52 million Americans with pre-existing conditions could lose coverage, face higher premiums, or become trapped in their existing plans,” reports Reuters.
In addition, House Whip Steve Scalise and Senate Majority Leader Mitch McConnell have both committed to revisiting the repeal of the ACA after the midterm elections.
Except for Senators Susan Collins, John McCain, Lisa Murkowski, and 20 House Republicans, every other Republican in Congress voted to repeal the ACA last year. A repeal would mean removing protections for those with pre-existing conditions. President Trump made the false claim on Twitter, “All Republicans support people with pre-existing conditions, and if they don’t, they will after I speak to them. I am in total support.” This statement is misleading for two reasons: first, Republicans are actively trying to revoke these protections, and second, Trump himself supports dismantling the ACA.
Some Politicians Are Claiming to Protect Health Care Provisions
Spin is common in politics, but some politicians seem to be outright fabricating their record regarding healthcare. Here are a few running for office who have made questionable promises to defend healthcare protections:
Ted Cruz, the incumbent Senator from Texas, claimed in a recent debate that he wants to protect coverage for pre-existing conditions. However, this is the same Ted Cruz who previously shut down the government over the ACA and introduced the Cruz amendment, which “explicitly allowed insurance companies to offer plans that lacked the protections” required by the ACA, according to the New York Times. Additionally, Texas leads the 20-state lawsuit against the ACA.
Josh Hawley is campaigning for Senate in Missouri, yet as the state’s attorney general, he is named in the lawsuit seeking to eliminate these protections while his ads claim to support those with pre-existing conditions.
Senator Dean Heller of Nevada has flip-flopped more than most on the issue of repealing the ACA. However, in April, he informed a group of Republican donors that the GOP would likely succeed in fully repealing the ACA after the midterm elections.
The New York Times’ Margot Sanger-Katz offers a more detailed analysis of various misleading ads.
In August, 10 Republican Senators introduced their own proposal to supposedly address the gap in pre-existing conditions coverage. The Ensuring Coverage for Pre-Existing Conditions Act states that insurers cannot make eligibility decisions based on a person's health status or medical history. However, as Politifact points out, the situation isn’t so straightforward:
The bill presents an option for insurers to refuse coverage if “they are unable to adequately deliver services.”
Allison Hoffman, a law professor at the University of Pennsylvania, sees this as a significant loophole.
Insurers could exclude coverage for someone’s pre-existing condition, even if they offered her a policy,” Hoffman said. “This alone undermines any claims that this law provides real protection for pre-existing conditions.”
The sole Republican in Congress who has consistently opposed efforts to repeal the ACA is Maine Senator Susan Collins. The GOP now realizes it faces a polling problem with its repeal attempts—people seem to really value having access to healthcare—which has led them to distort the truth to align with their current political agenda.
