What Is a Pre-existing Condition?

The American Health Care Act (AHCA), aka "Trumpcare," just passed the House of Representatives in hopes of repealing and replacing Obamacare. What is the controversy over pre-existing conditions? What is considered a pre-existing condition? And will you have to pay more for your plan if you have one?

Sanaz Majd, MD,
Episode #239

The American Health Care Act (AHCA)

On May 4, 2017 the U.S. House of Representatives passed (with a 217 versus 213 vote) the revised American Health Care Act (AHCA), aka “Trumpcare,” in hopes of repealing and replacing Obama’s Affordable Care Act (ACA). If you are interested in the nitty gritty details of the new bill, here is the official link.

The greatest controversial concern of the new bill is the potential loss of protection against pre-existing conditions, one of the pillars of the ACA.

What is a pre-existing condition? Well, any health condition that a doctor has previously diagnosed you with prior to your health plan taking effect is considered “preexisting.” This could mean essentially anything, from a simple cold to an active cancer. Prior to Obamacare, it was common practice for insurance companies to refuse coverage for a person with certain preexisting conditions. And for other diagnoses deemed less costly, they may decide to cover you but to charge you more.

Currently under Obamacare, insurance plans cannot refuse coverage or charge you more if you have a prior health condition, aka a "pre-existing condition."

Preexisting Conditions

Here are several of the top preexisting conditions according to Human Health Services in the non-elderly population (the same presumed population that will be purchasing in the exchange and most affected):

·         Hypertension (high blood pressure)

·         Behavioral Health Disorders (depression, anxiety, bipolar disorder, dementia, alcohol/substance abuse disorders, etc.)

·         High Cholesterol

·         Asthma or other chronic lung conditions

·         Osteoarthritis

·         Obesity

·         Heart Disease or other heart conditions

·         Diabetes

·         Cancer

·         Cerebrovascular disease (a common cause of stroke)

·         Infectious diseases (UTI, Pneumonia, MRSA, etc.)

Under the new bill, the ACHA still forbids insurers to outright deny coverage for those with preexisting conditions as they did prior to Obamacare, but it allows the potential increase in premium costs for these people. This can occur only if the state you live in requests a waiver to opt out of the default protection. The state will be required to present a case to show evidence that it is overall beneficial to their state, and will also be required to create a high-risk pool in order to offset the increased costs for those people. If the plans are expensive, these patients may not be able to afford it any longer, rendering them uninsured once again.

So it all depends on where you live and what your particular state elects to do.


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