WASHINGTON — Someone must be lying about health care coverage for pre-existing medical conditions.
Republicans, including President Donald Trump, are trying to drown out the chorus of doctor, patient and hospital groups that say people with chronic medical conditions could be priced out of coverage under the Republican health plan that narrowly passed the House of Representatives on Thursday.
Trump, House Speaker Paul Ryan, R-Wis., and the 216 House Republicans who voted for the bill say it protects these folks. They includes House Majority Leader Kevin McCarthy, R-Calif.
“Let me state it one more time: We will replace (Obamacare) with a system that protects pre-existing conditions,” McCarthy said on the House floor before Thursday’s vote.
So who’s telling the truth? It all depends on what you call a lie.
People with pre-existing conditions who could be priced out of coverage under the GOP legislation could ultimately get insurance through high-risk pools for the medically uninsurable. But such coverage pools have a long history of high costs, poor funding and limited benefits.
“Virtually every health care analyst that you talk to will tell you that these things just don’t work very well,” Andy Slavitt, former acting administrator of the Centers for Medicare and Medicaid Services, said during an online discussion this week with Rep. John Yarmuth, D-Ky.
Slavitt, who served under President Barack Obama, said Republicans were using the risk pools to falsely claim they were protecting coverage for people with pre-existing conditions.
“As long as we can throw someone with a pre-existing condition into a high-risk pool, we can say that they’re covered,” Slavitt said. “Even if we can charge them tens of thousands of dollars more. Even if we can give them something that doesn’t give them access to care. And even if we don’t fund it well enough. And that’s what I call a ‘high-five and a wink.’
” ‘Hey, we got this deal done. Hey, we can say we didn’t take away pre-existing conditions,’” Slavitt said of congressional Republicans, ” ‘but we’re going to give the (insurers) the opportunity to charge people whatever they want.”
In an editorial in Friday’s Washington Post, House Republican Conference Chair Cathy McMorris Rodgers, R-Wash, said high-risk pools and other programs to reimburse medical costs for sick plan members “have been successful in the past.” She defended the GOP health care proposal.
“Our plan establishes a program to provide federal resources for states to create high-risk pools, reduce out-of-pocket costs or promote better access to services,” McMorris Rodgers wrote.
Under the 2010 Affordable Care Act, individual health coverage must be offered to people with pre-existing conditions, which can be anything from asthma, acne and obesity to cancer, heart disease and AIDS.
Insurers couldn’t charge these folks more for coverage either, because the health law’s “community rating” provision bars insurers from varying premium rates based on health status or medical history under a process known as medical underwriting, which was discontinued under Obamacare.
Instead, the ACA requires everyone in the statewide coverage pool to pay the same rates, spreading the higher cost of sicker enrollees among all plan members. That was considered a crucial piece of the overhaul of the nation’s health care system that came to be known as Obamacare.
The GOP’s 2017 health care bill allows states to waive the community rating requirement so insurers could charge people with pre-existing conditions more. To do so, however, states must first come up with other ways to insure these sicker plan members, since they are almost certain to face unaffordable rates.
The most likely alternative under the GOP plan would be to steer many of these people into high-risk coverage pools for the medically uninsurable. That would allow private insurers to charge lower premiums for everyone else.
Although they covered 226,000 people in 35 states before the ACA was adopted, the risk pools were largely a failure, suffering from poor funding. That led to restrictions on enrollment and benefits, such as a standard six- to 12-month waiting period to cover pre-existing conditions. Pool coverage costs were typically 50 to 100 percent higher than private market rates.
Over their decades of availability, they weren’t a viable options for many sick people who needed them, because of their high costs, restricted benefits and poor government funding.
“Virtually every health care analyst that you talk to will tell you that these things just don’t work very well,” said Slavitt.
The GOP bill provides $15 billion over nine years and another $8 billion over five years to help cover people with pre-existing, chronic conditions. But that would cover only about 110,000 people, according to a new analysis from Avalere Health, a DC consulting firm. Avalere estimates that 2.2 million people with individual coverage have pre-existing conditions.
The GOP bill provides another $100 billion pot of money to help states, sick plan members and insurers pay medical costs. But if all that money — and the other $23 billion — went solely for people with pre-existing conditions, it would cover just 600,000 people, Avalere found.
That helps explain why the American Medical Association and other medical organizations are worried that many people will lose their coverage under the House bill.
The Affordable Care Act, also known as Obamacare, prohibited insurers from turning away consumers with pre-existing medical conditions, a practice that was once standard in the industry.
Among the conditions that once commonly made insurers deny coverage, according to a list assembled by the nonprofit Kaiser Family Foundation, were:
AIDS/HIV
Lupus
Alcohol abuse/drug abuse with recent treatment
Mental disorders
Alzheimer’s/dementia
Multiple sclerosis
Arthritis (rheumatoid), fibromyalgia, other inflammatory joint disease
Muscular dystrophy
Cancer within some period of time (e.g., 10 years)
Cerebral palsy
Severe obesity
Organ transplant
Congestive heart failure
Paraplegia
Coronary artery/heart disease, bypass surgery
Paralysis
Crohn’s disease/ulcerative colitis
Parkinson’s disease
Chronic obstructive pulmonary disease (COPD)/emphysema
Pending surgery or hospitalization
Diabetes mellitus
Pneumocystic pneumonia
Epilepsy
Pregnancy or expectant parent
Hemophilia
Sleep apnea
Hepatitis C
Stroke
Kidney disease, renal failure
Transsexualism
The American Health Care Act, as the House Republican health care bill is called, does not explicitly eliminate Obamacare’s coverage guarantee.
But the bill would allow states to obtain a waiver from the federal government to eliminate another Obamacare mandate that prohibits insurers from charging people with pre-existing medical conditions more for insurance.
That means that some people with pre-existing medical conditions could see their premiums spike dramatically, if the House bill becomes law.
In other words, a patient with diabetes, heart disease or cancer might still be “guaranteed” coverage, but only if he or she agreed to pay five or 10 times as much for a health plan.