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Previewing a House GOP Leaders’ Health Plan, #6: Little Protection for People With Pre-Existing Conditions

May 12, 2016 at 12:45 PM

Congressional Republicans who oppose health reform (the Affordable Care Act, or ACA) often say their plans to repeal and replace it would preserve one of its most popular elements: protections for people with pre-existing conditions.   But that’s not the case — and it probably won’t be the case with the health plan that House GOP leaders are crafting.

Generally, such plans would entirely repeal the ACA's market reforms — including prohibitions against insurers denying coverage or varying premiums based on a person's health status.  In their place, the proposals often substitute a “continuous coverage” requirement, protecting people from health insurer denials and higher premiums based on their health status only if they’d previously maintained coverage for at least 18 months or up to three years, depending on the proposal, with only short breaks of no more than two or three months allowed.  (In fact, House Speaker Paul Ryan, said last month that there should be no protection for people with pre-existing conditions and that such people should instead obtain coverage through high-risk pools.)

“Continuous coverage” would thus protect people far less than the ACA and only modestly more than the rules in place before it.  Many people would fall through the cracks.  Some 36 percent of Americans aged 4 to 64 — 89 million people — went without coverage for at least one month between 2004 and 2007, and about one-quarter of this group lost coverage more than once, one study found.

Under some “continuous coverage” proposals, individuals could also get a one-time open enrollment period to allow uninsured people with pre-existing health conditions to buy individual market coverage without being denied coverage or charged higher premiums.  But if someone with a pre-existing condition didn’t enroll then or subsequently went without coverage — as such coverage would likely be unaffordable due to inadequate financial assistance to help low- and moderate-income people buy it — insurers could deny them coverage or charge higher premiums based on their health status.  Between 20 and 66 percent of adults reported in 2009 that they had conditions (such as hypertension, mental health disorders, and cancer) that could leave them facing coverage denials or rate increases, according to the Government Accountability Office.

Consider how such a continuous coverage requirement would affect whether uninsured people with pre-existing conditions could buy and maintain health coverage.  A mother with diabetes who faces reduced work hours in the summer might go without health insurance for the rest of the year to afford basics such as rent, food for her kids, and gas to drive to work.  Under current law, she would likely owe a penalty under health reform’s individual mandate for not having coverage in those months.  But during that fall’s open enrollment period, she could enroll herself and her family in coverage for the following year — without fear of insurer denials or premium surcharges — despite her pre-existing condition.

With a continuous coverage requirement, however, insurers could use her diabetes to deny her coverage or charge a much higher premium than she paid before when she tries to buy coverage.  To regain access to the supposed protections of the replacement plans, she’d need to find an insurer in the individual market to sell her a plan or a job that provides health benefits.  In either case, she’d need to maintain those benefits for at least 18 months, and perhaps as much as three years, just to be able to buy coverage in the individual market in the future.

The ACA transformed the flawed individual insurance market into a viable source of health coverage.  A House GOP leaders’ replacement plan wouldn’t likely provide anything close to the current level of consumer protections for people with pre-existing health conditions.

Read the rest of our series previewing a House GOP leadership health plan here.

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