While the bill could weaken protections for people with pre-existing conditions and result in much more expensive insurance, the effect ultimately rests on states and insurers.
WASHINGTON — Rumors that the Republican health-care bill counts rape, domestic violence and ulcers as uninsurable pre-existing conditions are circulating among opponents of the bill. But these claims are overly simplistic.
The claims conflate what the bill, the American Health Care Act, says and its potential outcomes. While the bill could weaken protections for people with pre-existing conditions and result in much more expensive insurance, the effect ultimately rests on states and insurers. More important, the bill does not specify what a pre-existing condition is, nor does it allow insurers to deny coverage outright, although potentially they could set premiums beyond the reach of some sick consumers.
Here is an assessment:
Several liberal websites, such as the Resistance Report, suggested that the bill allows insurers to discriminate against rape victims: “Under Trumpcare plan, rape would be considered a pre-existing condition.”
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This needs context. The bill does not define rape as a pre-existing condition, and neither did insurers before the Affordable Care Act. It is possible that sexual-assault victims could see higher insurance costs, not because of the assault but because of resulting trauma or sexually transmitted diseases.
Variations of the claim began to circulate a year ago during the debate over the Affordable Care Act. Internet searches on whether rape is a pre-existing condition started to spike again Wednesday, the day before the House voted to repeal and replace the health-care law.
This appeared to follow the publication of an article on Rawstory: “Trumpcare could make sexual assault a pre-existing condition again — depending on where you live.” While the Rawstory headline is nuanced, the claims it may have inspired rarely are and thus often are less accurate.
Before the Affordable Care Act, insurers could practice “health-status underwriting,” or review health records to assess medical risk, and they could charge higher prices, or deny coverage, for conditions deemed to be more costly.
Insurers did not typically directly ask about sexual assault, or consider it in calculating insurance premiums. But they may have charged more “if they see that you’ve been screened for STDs, had treatment for an STD, taken HIV-preventive medication, had more than annual pelvic exams or had other follow-up encounters with the medical system,” said Sabrina Corlette, a research professor at Georgetown’s Health Policy Institute.
The Affordable Care Act mandated “community rating” — charging the same price regardless of health status — and “guaranteed issue” — offering coverage to any applicant.
The Republican health-care bill that passed the House would allow states to apply for a waiver from the community-rating rule for those who haven’t maintained continuous coverage, effectively allowing health-status underwriting again, if the Department of Health and Human Services grants the waiver. The bill also requires states to provide other health-care or cost-sharing options in lieu of community rating. But the bill does not allow states to waive guaranteed issue.
So if a state chooses to waive the regulation, insurers could charge much more for pre-existing conditions like HIV and trauma — not rape on its own — but they cannot deny coverage outright because of them.
Some websites, like Distractify, also claimed domestic abuse was a pre-existing condition under the bill: “The New AHCA Bill Lists Sexual Assault And Domestic Abuse As ‘Pre-Existing Conditions.’”
This needs context. Before the Affordable Care Act, several states did not have laws that prohibited insurers from counting domestic violence as a pre-existing condition. But it’s unclear if insurers actually denied coverage to victims of domestic violence in the years that immediately preceded passage of the health law.
Five states — Idaho, North Carolina, South Carolina, Vermont and Wyoming — do not bar insurers from considering domestic violence a declinable pre-existing condition, said Gretchen Borchelt, the vice president for reproductive rights and health at the National Women’s Law Center. Many insurers did deny coverage to domestic-violence victims in the 1990s, according to multiple surveys. When PolitiFact examined the issue in 2009, it found no evidence this was an ongoing or widespread practice.
Others, like the People for Bernie Sanders, shared an image claiming the bill would “end” insurance for those with pre-existing conditions: “217 Republicans voted today to end your health care if you suffer from” a range of medical issues, including AIDS/HIV, acne, depression, heartburn and ulcers.
This needs context. Many of the medical issues specified by the image, courtesy of Sen. Sherrod Brown, D-Ohio, were considered pre-existing conditions before the Affordable Care Act. But the bill would not literally “end” coverage because of them as it does not remove the act’s rule on guaranteed issue and requires the state waiver process.
Of all the conditions listed, the Kaiser Family Foundation found evidence that before the Affordable Care Act, about three dozen of them were declinable — from AIDS/HIV and lupus to severe obesity and diabetes. Others such as acne, allergies, migraines and ear infections could trigger higher costs or fewer benefits.
Kaiser also stated that the vast majority of people with these conditions have insurance through employers or other public options like Medicaid.
Again, this doesn’t mean that the Republican bill gives insurers a free pass to deny coverage because of these conditions, though people who, for example, cannot afford higher costs could lose insurance in states that receive a waiver from community ratings.
The bill could lead to “astronomically high premium increases for people with many of these conditions, if they buy insurance on their own and have a gap in coverage,” said Larry Levitt, an executive with Kaiser. “Even if states seek a waiver, not everyone with these conditions would lose insurance, but some certainly would.”
In states granted waivers, 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.’”
Although they covered 226,000 people in 35 states before the Affordable Care Act was adopted, the high-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.
The GOP bill would provide $15 billion over nine years and an additional $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 consulting firm. Avalere estimates 2.2 million people with individual coverage have pre-existing conditions.
The bill would provide $100 billion more 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.