Access to Care

Health reform: No going back on key market protections

Kevin B. O'Reilly , Senior News Editor

Look around the dinner table tonight. You are very likely to break bread with one person who has a pre-existing condition that, under the old rules, would have made it very difficult to secure health insurance coverage. Depending on the criteria used, as much as half of the non-elderly U.S. population has a pre-existing condition. That amounts to as many as 133 million people—patients who should not be discriminated against in the health insurance marketplace. The ban on using pre-existing conditions to deny coverage is one of the key health reforms that any replacement plan should maintain.

Between the passage of the Affordable Care Act (ACA) in 2010 and 2014, the share of non-elderly Americans with pre-existing conditions who went a full year without health coverage declined by 22 percent, according to a recent Department of Health and Human Services (HHS) issue brief. That is equivalent to 3.6 million patients across the country who were aided by this policy—known as guaranteed issue—along with other ACA provisions such as limits to age rating, premium and cost-sharing subsidies for insurance, and other measures. Guaranteed issue is most effective when combined with a policy of making all individuals, including healthy ones, responsible for purchasing insurance to avoid the so-called health insurance death spiral.

The issue of insuring people with pre-existing conditions—a health condition that a person already has when applying for, or enrolling in, a new health insurance policy—touches nearly every family. Prior to the protections enacted in the ACA, each insurer defined what constituted a pre-existing condition, encompassing conditions such as cancer, heart disease, asthma, hypertension and depression.

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When it was legal, health insurers collected information on demographic characteristics and medical history and often denied coverage. One survey found that one-third of individual market applicants were charged rates that were higher than the standard based on their personal characteristics or medical history. Meanwhile, another survey, released in 2009, found that more than one-third of patients were denied coverage, had exclusions placed on their policy due to pre-existing conditions, or were charged more, as the HHS brief noted.

The nonpartisan Kaiser Family Foundation estimated recently that 27 percent of non-Medicare-aged U.S. adults have one or more pre-existing conditions that would likely render them uninsurable if we went back to the medical underwriting practices that existed in states prior to the ACA.

Another key market reform that should be maintained is helping young adults secure insurance coverage through their parents’ health plans to age 26. The HHS reports that between 2010 and October 2013 a whopping 2.3 million young adults aged 19 to 25 gained health insurance under the ACA provision that allows people under the age of 26 to stay on a parent’s plan, leading to a decline in the uninsured rate for young adults from 34.1 percent to 26.7 percent in that period. Another 3.8 million young adults gained coverage between October 2013 and early 2016, with 13.9 percent of young adults remaining uninsured. The AMA has policy that supports making coverage available through parents’ plans to age 28, and believes the accessibility up to age 26 should at least be maintained.

Last, but certainly not least, there should be no lifetime cap on health insurance benefits. The value and security provided by health insurance should not be diminished by limiting coverage across a patient’s life span in those cases where they have a costly disease or condition.

The ACA is imperfect. There are serious concerns about the stability of the individual insurance market and the choice of health plans available under the law. But as policymakers move ahead with considering a replacement, they should not lose sight of the real advances in access to coverage that have been made, affecting millions of Americans.

Read more about the AMA's comprehensive vision for health-system reform, refined over more than two decades by the AMA’s House of Delegates, which is composed of representatives of more than 190 state and national specialty medical associations.