Guest Commentary | Candidate rhetoric and pre-existing conditions

Guest Commentary | Candidate rhetoric and pre-existing conditions


With the November midterm elections approaching, it's difficult to avoid the seemingly endless stream of campaign ads, with health care often a top focus.

With health care an important voter issue, it's not surprising that candidates are either touting their records, or more likely, demeaning their opponent's. A key issue for many is "pre-existing conditions."

By definition, a pre-existing condition is any personal illness or health condition that was known and existed before a person's health benefits went into effect, such as asthma, diabetes, cancer, dementia, multiple sclerosis, HIV/AIDS or mental disorders.

For many Americans, this issue is both personal and important. Most people either have a pre-existing condition or know of a friend or relative with one. According to the U.S. Department of Health and Human Services, as many as 130 million adults under the age of 65 have pre-existing conditions. The Kaiser Family Foundation puts the number at about 25 percent of the country's under-65 population.

Before 2014, insurance companies could and did routinely decline covering people who had ongoing medical conditions or recent illnesses. Some would offer policies to those with health conditions but excluded coverage for those very conditions. Insurance companies could also cancel coverage by not renewing policies for people who became ill when the policy year ended. Given that about 20 percent of insurance enrollees account for 80 percent of expenses, those with pre-existing conditions or illnesses are viewed as "burning buildings," which insurers try to identify to avoid risk rather than manage risk.

With passage of the Affordable Care Act (ACA), aka Obamacare, rules went into effect after Jan. 1, 2014, whereby insurance companies were not allowed to deny coverage to individuals with pre-existing conditions, charge you more or refuse to pay for essential benefits for any condition you had before coverage started.

No doubt the ACA has been controversial. Since 2011, Republicans vowed to "repeal Obamacare on day one" and voted more than 60 times to abolish, repeal, undo or tweak it, maintaining that it is unsustainable and government overreach. Especially controversial was the individual mandate to purchase coverage or be monetarily penalized (now repealed). Democrats either support the ACA or say it hasn't gone far enough, since it left 28 million Americans uninsured and millions more with unaffordable premiums, deductibles and co-payments.

However, several provisions of the ACA have strong public support. Most Americans approve allowing children to remain on their parents' coverage until age 26. Most also approve of banning insurers from denying coverage based on pre-existing conditions. Most Americans agree that if you are sick, you should be able to get affordable health insurance. In addition, more than 70 percent say that it should be illegal for insurers to charge more for people who have pre-existing conditions. Without significant cost controls, providing affordable coverage to those with pre-existing conditions requires either having a larger pool of healthy people enrolled or adequate public subsidies to cover the increased cost of providing care. Not surprisingly, in a highly polarized political environment, there is no consensus on health reform between parties.

While there is strong public support for coverage of pre-existing conditions, how to accomplish it remains elusive. It has become a popular issue in the midterm elections. Many candidates, from both parties, tout their supporting coverage of pre-existing conditions but differ in how this is accomplished. Democrats favor a universal approach, while Republicans prefer decision making at the state level.

Supporters of the ACA would not allow insurance companies to deny coverage or allow them to charge individuals with pre-existing conditions more for coverage. The ACA also limits the amount insurance companies can charge older Americans to three times what they charge younger enrollees. Supporters of the Republican-sponsored American Health Care Act would let states apply for pre-existing coverage waivers allowing for health status underwriting for individuals not maintaining continuous coverage. Unlike the ACA, the AHCA gives states the authority to change the pricing rules for people who do not stay insured year-round. States obtaining a waiver would have to establish a high-risk pool to assist people with pre-existing conditions to get coverage. Also, insurance companies could charge older Americans up to five times what they charge younger enrollees. States could apply for waivers to increase this ratio.

Both parties say they support protecting people. Voters would be wise to discount what is heard in campaign ads and "look under the hood" for each candidate's position on this important issue.

Thomas O'Rourke is professor emeritus of community health at the University of Illinois.