According to theKaiser Family Foundation, more than a quarter of adults below the age of 65 (approximately 52 million people) had pre-existing conditions in 2016.
Conditions can be broken down into two further categories, according to Lisa Smith ofInvestopedia:[3]
Most insurance companies use one of two definitions to identify such conditions. Under the "objective standard" definition, a pre-existing condition is any condition for which the patient has already received medical advice or treatment prior to enrollment in a new medical insurance plan. Under the broader, "prudent person" definition, a pre-existing condition is anything for which symptoms were present and a prudent person would have sought treatment.
Which definition may be used was sometimes regulated by state laws. Some states required insurance companies to use the objective standard, while others required the prudent person standard. 10 states did not specify either definition, 21 required the "prudent person" standard, and 18 required the "objective" standard.[4]
According to the Kaiser Family Foundation, more than a quarter of adults below the age of 65 (approximately 52 million people) had pre-existing conditions in 2016.[5]
Regulation of pre-existing condition exclusions in individual (non-group) and small group (2 to 50 employees) health insurance plans in theUnited States was left to individualU.S. states as a result of theMcCarran–Ferguson Act of 1945 which delegated insurance regulation to the states and theEmployee Retirement Income Security Act of 1974 (ERISA) which exempted self-insured large group health insurance plans from state regulation. After most states had by the early 1990s implemented some limits on pre-existing condition exclusions by small group (2 to 50 employees) health insurance plans, theHealth Insurance Portability and Accountability Act (Kassebaum-Kennedy Act) of 1996 (HIPAA) extended some minimal limits on pre-existing condition exclusions forall group health insurance plans—including the self-insured large group health insurance plans that cover half of those with employer-provided health insurance but are exempt from state insurance regulation.[8][9][10][11][12][13]
Individual (non-group) health insurance plans[14][15]
Maximum pre-existing condition exclusion period (states that permitted elimination riders permanently excluding pre-existing conditions noted byitalics and asterisk*)
Maximum look-back period for pre-existing conditions
6 months: 50 states + DC
Pre-existing condition exclusions were prohibited for HIPAA-eligible individuals (those with 18 months continuous coverage unbroken for no more than 63 days and coming from a group health insurance plan).
Individual (non-group) health insurance plans could exclude maternity coverage for a pre-existing condition of pregnancy.[2]
Group health insurance plans sponsored by employers with 15 or more employees were prohibited by thePregnancy Discrimination Act of 1978 from excluding maternity coverage for a pre-existing condition of pregnancy; this prohibition was extended to all group health insurance plans by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).[2]
Advocates against pre-existing condition rules argue that they cruelly deny people in need of treatment.State Farm spokeswoman K.C. Eynatten has said, "We realized our position was based on gut feelings, not hard numbers... we became aware that we were part of the reason a woman and her children might not leave an abuser. They were afraid they'd lose their insurance. And we wanted no part of that."[17] Jerry Flanagan, health-care policy director ofConsumer Watchdog, has stated that "insurance companies want premiums without any risk" and go to extreme "lengths... to go to make a profit".[18] InsureMe, an insurance quote provider website, has argued that even though health insurance is basically to protect people from very high costs of health care, the commercial health insurance system is not playing fair and are always trying to avoid risk in order to boost their profits.[19]
The rationale behind pre-existing condition clauses, according to those who defend the policies, is that they reduce the cost of health insurance coverage for those who still receive it, thus giving more people an opportunity to afford insurance in the first place.[17][22] TheSan Francisco Chronicle has reported that "[c]osts for those with coverage could go up because people in poor health who'd been shut out of the insurance pool would now be included... they would get medical care they could not access before."[22]SenatorMike Enzi, aRepublican fromWyoming, has voted to allow insurance companies to consider domestic violence as a pre-existing condition and supported his vote by saying that covering such people could raise insurance premiums to the point where it would preclude others from buying it. He has remarked that "If you have no insurance, it doesn't matter what services are mandated by the state".[17][23]
According to aReason.comlibertarian opinion blog by Peter Suderman, the 'Pledge to America' issued by theRepublican Party in September 2010 stated, "Health care should be accessible for all, regardless of pre-existing conditions or past illnesses.... We will make it illegal for an insurance company to deny coverage to someone with prior coverage on the basis of a pre-existing condition."[24] In a March 3, 2010, address, PresidentBarack Obama said that coverage denied to those with pre-existing conditions is a serious problem that would only grow worse without major reforms.[25] In a September 2010 visit withFalls Church, Virginia, residents, Obama referred to a woman with an eye condition and a woman withnon-Hodgkin's lymphoma as personal examples in the audience of those benefiting from changing pre-existing condition rules.[26]
ATime-Abt SRBI poll in late July 2009 found that a large majority of Americans (80%) favored a requirement that insurance companies insure people even if they have pre-existing conditions.[27]
The public's most unanimous and bipartisan support is saved for a proposal to have the federal government require that health insurance companies cover anyone who applies, even if he/she has a pre-existing condition. Overall, eight in ten back the proposal, including 67 percent of Republicans, 80 percent of political independents and 88 percent of Democrats.
