What’s a “Pre-existing condition”?

The GOP is again talking about just passed a “better” plan to replace the ACA, and thus, despite Trump’s “promises”, people are talking about the importance of not denying health insurance to people due to pre-existing conditions. You’re going to hear truly tragic stories about people surviving or not because of this, about people who would’ve been excluded from health insurance in the past and are now stable and productive members of society, about people being left to die because of lack of money or accident of birth.

I don’t have any such story. But I think it’s important to understand that we’re not just talking about multi-million-dollar expenses for comparatively rare conditions and tragic accidents. This used to be be far more widespread.

Before the ACA

Before the ACA, as a single, male, healthy ~30-year-old with almost no adult medical history, I was shopping for health insurance, because my parents had been paying through the nose to add me to their plan on a rider since I’d aged out of their coverage. So I shopped around and found something that I could afford that included a good number of medical facilities in my area. It wasn’t cheap, and I was going to feel the pinch, but I could swing it.

I applied. You didn’t “sign up” in those days—you asked permission to get coverage, and they decided whether or not you were good enough, and if you were, what the rate would be.

After a couple weeks, I got the paperwork back to review.

Price: as advertised.

Coverage: as expected, except…

I’d been to a doctor a few months earlier for a knee injury—I’d pulled something. Prescription at the time was: “take it easy, do some stretches once it stops hurting, and if it doesn’t clear up in ~6 months, come see us again”. It had been ~1 year, and I hadn’t needed to see anyone about my knees since.

But because of this, the insurer was putting a rider on, excluding coverage for my knees. My mom has had [minor] knee problems for as long as I can remember, so there’s a good chance that even if I’m careful I’ll end up needing some sort of knee-related medical attention at some point in my life. And this wasn’t “no coverage for that lingering knee injury” or “no coverage for knee treatments in the first 12 months” or something like that. Nope. This was “no coverage for anything knee related for as long as you have insurance with us.” By the terms of the coverage, if I got in a car accident and needed fixing, any repairs to my knees wouldn’t be covered (even if everything else were).

And they hadn’t even asked about family history, so it wasn’t because of that (not that that would justify or excuse it).

They claimed that it was because the injury was within the previous 12 months—but then why not say “won’t be covered until 12 months from the original injury have elapsed without claims”? or some such?

From my perspective, in my late 20s and not having had any real medical problems other than injuries and wisdom teeth, this was them saying “we’ll be happy to give you health insurance, but not for the one thing you’re likely to actually need it for.” And in that era, such exclusions tended to carry over. The next insurance company was likely to say “they excluded your knees; we’ll exclude your knees”.

And this was not, from everything I’ve heard, at all unusual—maybe a bit more extreme (I didn’t have an ongoing history of knee expenses—er, problems—just the one, minor injury), but the basic principle of excluding anything the insured would rack up significant expenses for was widespread.

So What?

So, when we talk about allowing health insurers to consider pre-existing conditions, yes, we’re talking about them being able to deny someone with cystic fibrosis or a heart condition or cancer. Yes, it will mean people either die or get taken care of as charity cases or end up supported by the government (though they’re working to limit who’s eligible for Medicare and Medicaid, too). This is tragic and horrible and the antithesis of the whole point of healthcare.

But if we really return to the pre-ACA days, we’re also talking about otherwise-healthy people being denied insurance for past occurrences that are presumably healed. Otherwise-healthy people having insurance that specifically excludes coverage for whatever personal medical issue they are most likely to actually need healthcare for. Basically, health insurance that intentionally does not provide coverage for significant expenses, but is instead carefully crafted to provide excellent coverage that you may never need while avoiding coverage that you are likely to use. That is far less tragic—because if it’s minor enough that they give you insurance but exclude it, rather than deny you completely, it’s probably also something you can live with (it’s been decades now, and I have yet to need any healthcare for my knees and, knock on wood, I never will, so even if they were excluded it wouldn’t materially affect me)—but equally immoral.

That’s not health insurance; that’s a scam.


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