# Pre-existing Conditions

Most Iowans with pre-existing conditions won't get help until 2014

Last week the federal departments of Health and Human Services, Labor, and Treasury “released interim final regulations implementing five of the insurance enrollee protections of the Patient Protection and Affordable Care Act” (the official name for the health insurance reform law adopted in March). Timothy Jost analyzed the regulations for the Health Affairs blog, and his whole post is worth reading. While a lot of uncertainty surrounds the new rules, the cost of compliance is expected to be low. Jost finds that “[r]elatively few people will directly benefit” from the health insurance reform, but there will be “[l]arge benefits for those who are affected.”

During the last presidential campaign and more than a year of health care debates on Capitol Hill, countless politicians swore they were committed to ending discrimination against Americans who have pre-existing medical conditions. After reviewing the interim regulations, Jost has good news and bad news for adults who lack health insurance because of a medical problem.

The ban on preexisting conditions exclusion found in the Affordable Care Act is much broader than the preexisting condition exclusion imposed by the Health Insurance Portability and Accountability Act [of 1996].  It prohibits any limitation or exclusion of benefits in a group or individual plan based on the prior existence of a medical condition.  The provision not only prohibits the exclusion of coverage of specific benefits based on a preexisting condition, but also the complete exclusion from the plan of a particular person if the exclusion is based on a preexisting condition.   The regulation does not, however, prohibit coverage exclusions that apply regardless of whether a condition is a preexisting condition or not.   The provision applies to enrollees under the age of 19 effective the first plan year beginning after September 23, 2010, but to adults only beginning in 2014.

In the summer of 2009, many progressives were disturbed to learn that the draft House health care bill delayed implementation of the pre-existing condition provision until 2013 (the date was pushed back to 2014 later in the legislative process). Why should Americans with previous or chronic medical problems continue to be denied health insurance for four more years? Don’t worry, we were told: new high-risk pools will be created to bridge the gap for people with pre-existing conditions.

We are now learning more about how the new Pre-Existing Condition Insurance Plan will operate. Eligible Iowans will be able to start applying for our state’s plan on July 15. But uh oh:

The new program, expected to start in a few weeks, will be financed with $35 million in federal money from the new health care reform law. That money will be enough to help only 975 Iowans, state administrators have concluded.

“$35 million doesn’t cover as many people as you’d hope,” said Susan Voss, Iowa’s insurance commissioner.

Another twist is that Iowans who participate in the state’s current high-risk insurance pool won’t be able to switch into the new pool, which will be significantly less expensive.

Federal experts have estimated that 34,500 Iowans could be eligible for the new pool.

The money is supposed to last until 2014, when private insurers will be banned from discriminating against people with pre-existing health conditions. At that point, such people should be able to buy their own insurance just like anyone else, health reform proponents say.

You see immediately what Jost was getting at: few Iowans with pre-existing conditions will benefit from the new high-risk pool (perhaps 3 percent of the eligible population). For those who get in, though, the benefits are immense: insurance for about the same price a healthy person would pay.

While helping 950 uninsurable Iowans obtain coverage is significant, it would have been better to implement the health insurance reform on a faster timetable. Because Congress lacked the political will to impose significant costs on insurance companies, 97 percent of Iowa adults with pre-existing conditions will have to wait until 2014 to reap the full benefit of the health reform.

That sounds like over-promising and under-delivering to me. But I can’t say I wasn’t warned a long time ago.

UPDATE: Democrats will talk up the health reform changes that take effect sooner, such as new Medicare reimbursement rates. Those are expected to increase payments to Iowa doctors and hospitals. But the public case for health care reform wasn’t built on wonky issues like Medicare reimbursement rates. It was a simple moral argument, and not letting insurers discriminate against people with a pre-existing condition was at its core.  

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Iowa to form new insurance pool for people with pre-existing conditions (updated)

Governor Chet Culver announced Friday,

Iowa will accept $35 million in federal funds over the next four years to operate its own temporary health insurance plan for high-risk individuals.  This step will help cover uninsured Iowans as the country transitions toward implementation of federal health insurance reform.

“Every Iowan should have access to affordable health care,” Governor Culver said. “This action is an important first step in reaching this goal.  These funds will allow Iowans who have been among the uninsured for extended time periods to get coverage, in spite of health problems and without waiting periods for existing conditions.”

Iowa will establish a new pool alongside its current high-risk pool structure that will comply with the federal requirements. Under the terms of the federal funding formula, Iowa will be eligible to receive a grant of approximately $35 million in reimbursements to subsidize the cost of the fund until 2014. The state’s next step will be to submit a plan for federal approval.

Here are more details about the program:

Consumers will be eligible for the new pools if they have a pre-existing medical condition and have not had insurance for at least six months.

They will pay premiums that parallel rates being offered by commercial insurers to healthy people on the individual market. Many existing high-risk pools charge such high premiums that many people cannot afford the coverage. Today, high-risk pools in 34 states cover only about 200,000 people.

Individuals who sign up for the new pools also will not have to pay more than $5,950 a year out of their pockets for medical care, according to the legislation.

According to this backgrounder posted at Iowa Independent, the new high-risk pool could serve more than ten times the number of people could affect many people not enrolled in Iowa’s current high-risk pool:

“This is an opportunity for the state to show whether it is ready to put a critical component of health reform – covering people with pre-existing conditions – on a faster track,” said Andrew Cannon, research associate for the nonpartisan Iowa Policy Project and author of a new policy brief on the topic.

Cannon said more than 34,500 Iowans could be eligible for Iowa’s existing high-risk pool or a new one the state may create if the state chooses to act now. The federal health-reform legislation allocated $5 billion nationally to states to provide temporary coverage as a bridge to full implementation of health reform, which will require all insurance companies to accept applicants without consideration of a person’s medical condition by 2014.

Iowa created its high-risk pool program in 1987, now known as the Health Insurance Plan of Iowa (HIPIowa). It serves 2,732 state residents.

High-risk pools such as HIPIowa are designed to help individuals who do not have health insurance through work, do not qualify for Medicaid and cannot afford or qualify for individual coverage because of a pre-existing medical condition. HIPIowa’s premiums are about half as expensive as the standard rate for plans sold on the private market, Cannon said, but in many cases those premiums still exceed potential enrollees’ ability to pay.

UPDATE: The Des Moines Register quoted HIPIOWA Executive Director Cecil Bykerk and State Senator Jack Hatch as saying federal funding will allow about 1,000 people to be covered in the new high-risk pool before 2014. That’s a small fraction of the number of Iowans who might be eligible for the program, according to the Iowa Policy Project’s estimate.

The Des Moines Register quoted Rod Roberts and spokesmen for Terry Branstad and Bob Vander Plaats as saying they oppose participation in this new federal program. I don’t know how quickly the new pool will be up and running, but I’d like to see the Republican nominee for governor explain to Iowans with pre-existing conditions why they should have to go without affordable insurance coverage until 2014. Remember, the federal government is subsidizing the cost of operating the new pools.

As of April 30, officials in 28 states had informed the federal Department of Health and Human Services of plans to create new high-risk pools, while officials in at least 15 states had declined to participate for fear that federal funds may be insufficient to cover the operation of these pools until 2014.

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Sebelius warns insurers against excluding sick kids

Health and Human Services Secretary Kathleen Sebelius wrote to the head of the insurance industry’s lobbying arm yesterday warning against efforts to continue to deny coverage to children with pre-existing conditions. Excerpt from the letter, which you can download as a pdf file at Greg Sargent’s blog:

Health insurance reform is designed to prevent any child from being denied coverage because he or she has a pre-existing condition. Leaders in Congress have reaffirmed this in recent days in the attached statement. To ensure that there is no ambiguity on this point, I am preparing to issue regulations in the weeks ahead ensuring that the term “pre-existing condition exclusion” applies to both a child’s access to a plan and to his or her benefits once he or she is in the plan. These regulations will further confirm that beginning in September, 2010:

*Children with pre-existing conditions may not be denied access to their parents’ health insurance plan;

*Insurance companies will no longer be allowed to insure a child, but exclude treatments for that child’s pre-existing condition.

I urge you to share this information with your members and to help ensure that they cease any attempt to deny coverage to some of the youngest and most vulnerable Americans.

A spokesperson for House Speaker Nancy Pelosi sent Sargent the following statement:

The intent of Congress to end discrimination against children was crystal clear, and as the House chairs said last week, the fact that insurance companies would even try to deny children coverage exemplifies why the health reform legislation was so vital. Secretary Sebelius isn’t going to let insurance companies discriminate against children, and no one in the industry should think otherwise.

Let’s hope this works. I wouldn’t be surprised to see insurance companies challenge the new regulations in court. They must have been counting on that loophole to save them money during the next few years.

UPDATE: David Dayen is probably right about the insurance companies’ motives here:

You can pretty much figure out AHIP’s game here. With no restrictions on cost until 2014, the industry can raise their premium prices almost at will. Even the bad publicity suffered from that 39% rate hike of Anthem Blue Cross [of California] plan has not stopped that scheduled increase from taking effect in May. And when outrage is expressed by families facing double-digit rate hikes, AHIP will clear their throats and blame the pre-existing condition exclusion for children, forcing the poor insurance companies to take on a sicker risk pool and raise prices to survive.

Except covering kids is fairly cheap to begin with. And the universe of kids with a pre-existing condition who aren’t covered through SCHIP, Medicaid, or an employer plan is extremely small. So by making a big issue of this, AHIP potentially sets up large rate hikes in the 2010-2014 period that aren’t at all justified.

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House health insurance vote thread

UPDATE: The vote on the rules for the reconciliation bill debate passed 224-206 (roll call). The final vote on the Senate bill will be late tonight.

FINAL UPDATE: The House approved the Senate bill 219-212, with no Republicans voting in favor and 34 Democrats voting against (roll call). It’s clear House leaders did not have the votes without the Stupak bloc.

VERY FINAL UPDATE: Two more roll calls: a Republican-backed poison pill that would have inserted the president’s executive order language on the Hyde amendment into the reconciliation fixes failed 232-199. Then the House passed the reconciliation fixes to the Senate bill by a vote of 220-211.

The House of Representatives began debating the health insurance reform legislation on Sunday afternoon. Speaker Nancy Pelosi is using the gavel Representative John Dingell’s father used the day the House approved Medicare in 1965. I will update this post as votes are taken on the reconciliation package and later on the Senate’s bill.

Some kind of new deal appears to have been struck with Bart Stupak and his group of anti-abortion Democrats. Link to follow later when more details become available. I assume this means House leaders didn’t have 216 votes without the Stupak bloc, which is how the whip counts have been looking. (UPDATE: The president agreed to issue this executive order affirming that the health insurance reform bill “maintains current Hyde Amendment restrictions governing abortion policy and extends those restrictions to the newly-created health insurance exchanges.” The executive order allows Stupak and his bloc to vote for the bill without the appearance of caving.)

Republicans are making fools out of themselves warning about the death of liberty and the “government takeover.” Gubernatorial candidate Rod Roberts has filed amendments to two Iowa House bills seeking to “challenge the constitutionality of President Obama’s plan to nationalize the health care industry.” He also says that as governor he would sue the federal government, claiming that health insurance reform violates the 10th Amendment to the U.S. Constitution. Roberts is copying a Bob Vander Plaats campaign promise here, which supports my view that Roberts’ main function in the governor’s race is to undermine Vander Plaats in the GOP primary.

Meanwhile, Democrats are making fools of themselves claiming that passing a Republican plan from 1993 is something to cheer about. We should be ashamed that corporate interest groups got everything they wanted in this bill, to the extent that the lobbying arm of the pharmaceutical industry is running ads supporting the bill. We should be outraged by all of President Obama’s broken promises on health care reform and the fact that he lied about supporting a public health insurance option after secretly agreeing to leave that out of the bill.

I don’t know whether better health care reform was achievable. Certainly Big Tent Democrat is right that progressives botched the negotiating process (see also here), but once the president decided not to do anything that angered corporate groups, we were probably stuck with what we’re getting. Some people will benefit from subsidized insurance and new primary health care clinics, but other people will be forced to downgrade their coverage, and there will be no new competition for the insurance companies that have near-monopolies in most of the country. I doubt this reform will reduce insurance company abuses, and I doubt it will save tens of thousands of lives a year, and I doubt future Congresses with (at best) smaller Democratic majorities will improve it in any meaningful way, but let’s hope I am wrong.

Failing to pass the bill might have hurt Democrats more in the short term, but I think over-promising the benefits will hurt us badly later. When Americans continue to face medical bankruptcies, and some insured people continue to find medical care unaffordable, and “wellness incentives” become the new method of discriminating against people with pre-existing conditions, Democrats will be blamed.

Listing the alleged “progressive victories” in this bill is just an exercise in self-delusion. This bill was written for the benefit of corporate groups. Many provisions that would have been in the public interest have been left out. It’s a disgrace that large Democratic majorities produced this reform, and it’s one reason the Democratic National Committee, the Democratic Congressional Campaign Committee and the Democratic Senatorial Campaign Committee will get no money from me for the forseeable future.

You can claim the bill is a slight improvement on the status quo, but calling it “progressive” or a sign of interest groups in decline is an insult to everyone’s intelligence. Not as stupid as calling it a “government takeover,” but almost as deceptive.

Share your own thoughts in this thread, whether or not you feel like celebrating today’s “historic victory.”

UPDATE: Republican strategist David Frum argues that the GOP made a huge mistake by refusing to make a deal with Obama on health care reform:

Barack Obama badly wanted Republican votes for his plan. Could we have leveraged his desire to align the plan more closely with conservative views? To finance it without redistributive taxes on productive enterprise – without weighing so heavily on small business – without expanding Medicaid? Too late now. They are all the law.

No illusions please: This bill will not be repealed. […]

We followed the most radical voices in the party and the movement, and they led us to abject and irreversible defeat.

There were leaders who knew better, who would have liked to deal. But they were trapped. Conservative talkers on Fox and talk radio had whipped the Republican voting base into such a frenzy that deal-making was rendered impossible. How do you negotiate with somebody who wants to murder your grandmother? Or – more exactly – with somebody whom your voters have been persuaded to believe wants to murder their grandmother?

I’ve been on a soapbox for months now about the harm that our overheated talk is doing to us. Yes it mobilizes supporters – but by mobilizing them with hysterical accusations and pseudo-information, overheated talk has made it impossible for representatives to represent and elected leaders to lead.

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Breastfeeding infant labeled obese, denied health insurance

Breastfed babies can be long and lean, short and fat, or anywhere in between. But I never heard of an insurance company citing a breastfeeding infant’s “obesity” as a pre-existing condition before reading this story from the Denver Post:

By the numbers, [four-month-old] Alex [Lange] is in the 99th percentile for height and weight for babies his age. Insurers don’t take babies above the 95th percentile, no matter how healthy they are otherwise. […]

Bernie and Kelli Lange tried to get insurance for their growing family with Rocky Mountain Health Plans when their current insurer raised their rates 40 percent after Alex was born. They filled out the paperwork and awaited approval, figuring their family is young and healthy. But the broker who was helping them find new insurance called Thursday with news that shocked them.

” ‘Your baby is too fat,’ she told me,” Bernie said.

Up until then, the Langes had been happy with Alex’s healthy appetite and prodigious weight gain. His pediatrician had never mentioned any weight concerns about the baby they call their “happy little chunky monkey.” […]

“I’m not going to withhold food to get him down below that number of 95,” Kelli Lange said. “I’m not going to have him screaming because he’s hungry.”

Good call, Mrs. Lange. There is “no evidence to support ‘dieting’ or substituting other foods or liquids for human milk to reduce weight gain.”

It’s outrageous for an insurance company to use Alex’s weight at four months of age as an excuse to deny coverage. Not that exclusions for other “pre-existing conditions” (such as a benign heart murmur that a child would grow out of without treatment) are any more defensible.

Also, the Lange family wouldn’t have been shopping around for new coverage if their previous carrier hadn’t raised their rates by 40 percent after Alex was born. I remember our insurance premiums went up quite a bit after our second child was born, but I don’t think it was by that much. Then again, they went up 10 percent last year even without any new babies or health problems in our family.

Share any relevant thoughts in this thread.

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Reform won't end cherry-picking by private insurers

All of the health care reform bills under consideration in Congress would prohibit insurance companies from refusing to cover people because of prior health problems. "Guaranteed issue" is the wonky name for this ban on discrimination because of pre-existing conditions. Unfortunately, various economists and health care experts told David Hilzenrath of the Washington Post that "simply banning medical discrimination would not necessarily remove it from the equation [...]."

If insurers are prohibited from openly rejecting people with preexisting conditions, they could try to cherry-pick through more subtle means. For example, offering free health club memberships tends to attract people who can use the equipment, says Paul Precht, director of policy at the Medicare Rights Center.

Being uncooperative on insurance claims can chase away the chronically ill. For people who have few medical bills, it is less of a factor, said Karen Pollitz, research professor at the Georgetown University Health Policy Institute.

And to avoid patients with costly, complicated medical conditions, health plans could include in their networks relatively few doctors who specialize in treating those conditions, said Mark V. Pauly, professor of health-care management at the University of Pennsylvania's Wharton School. [...]

America's Health Insurance Plans, a lobbying group for health insurers, has endorsed the idea of guaranteeing individuals access to coverage regardless of their medical history -- if that guarantee is part of a larger plan to help the uninsured pay for coverage and bring everyone into the insurance market.

At a more nuts-and-bolts level, AHIP has been trying to shape the legislation in ways that could help insurers attract the healthy and avoid the sick, though it has given other reasons for advancing those positions. In a recent letter to Baucus, AHIP President Karen Ignagni said benefit packages "should give consumers flexible options to meet diverse needs."

If the final health care reform bill has no public health insurance option, many chronically ill Americans are likely to be left outside the system as insurers find new ways of denying coverage or dropping policy-holders.

Even if the final bill includes a limited public option, cherry-picking by private insurers could set up the public plan for failure. President Obama has endorsed the idea of making the public option available only to people who are currently uninsured, meaning it will serve a disproportionate number of chronically ill people. That will drive up costs of operating the public plan.

I don't have an answer for this problem, beyond feeling depressed that corporate groups like AHIP have so much sway with Congress. If Americans with prior health issues are still facing discrimination after Obama signs what he claims to be sweeping "health insurance reform," the political backlash against Democrats could be severe.

UPDATE: MyDD user Bruce Webb wasn't impressed by Hilzenrath's article. I've posted his rebuttal after the jump.

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