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Seeking Higher Ground: The problem with pre-existing conditions

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By Nicolette Toussaint

Last week, during a Glenwood Springs town hall meeting with Senator Michael Bennet, many locals worried about congress replacing the Affordable Care Act (ACA). Bennet thinks the senate will consider the replacement, the American Health Care Act (ACHA), sometime before July 4.

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Although individual market ACA choices haven’t been good in our valley — along with a couple other mountain counties, we pay the highest premiums in the nation — Senator Bennet sees nothing in ACHA that’s going improve our condition.

I’m not surprised.

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Before aging into Medicare last fall, I repeatedly wondered whether the high cost and low quality of care available locally would eventually force me to leave this valley. I wasn’t alone; I know several people here who pay more for ACA insurance than they pay for housing!

While the proposed ACHA does prevent health insurers from outright denying coverage to people with “pre-existing conditions,” it doesn’t limit costs. State-run “high-risk pools” (which existed pre-ACA) are proposed to help, but according to an AARP report, premiums could reach as high as $27,500 a year. That’s in states that actually have pools (not all states must run them) and in states that don’t run out of money (which is what happened pre-ACA.)

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ACHA wouldn’t improve much on the situation I faced when I moved here in 2011, prior to landing a job with health care. Because I had worried about losing coverage when I left my California job, I had stockpiled medications for two pre-existing conditions, asthma and depression. I had received excellent medical care at Kaiser San Francisco for 28 years, courtesy of various employers. That had enabled me to seek help for my two pre-existing conditions, but it also meant that they were on my medical records.

Sure enough, they kept me from getting medical insurance prior to passage of ACA.

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Ironically, neither of my pre-existing conditions now exist. It turned out that the asthma was sparked by polluted urban air and allergies to plants that don’t grow here. The depression was largely a reaction to San Francisco’s persistent fog. The prescriptions I had stockpiled — a year’s worth of drugs that would have would cost over $5000 under that policy I couldn’t get — wound up being thrown out. What a sorry waste!

But ACHA could return us to the bad old days. While only about one out of every 33 babies born each year in US each year has a birth defect, from then on out, life is full of dings and scrapes. The Kaiser Health Foundation estimates that 27 percent of adults under 65 have health conditions that would have made them uninsurable under pre-ACA underwriting practices. “Pre-existing conditions”, as variously defined by ACHA health insurers, would include about 50 health issues ranging from AIDS and acne to high cholesterol and cancer.

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That’s no big worry for those covered by employer-sponsored health care, but life tends to be what happens when you’re making other plans. Nearly 20 percent of Americans lost jobs during the last recession and can testify that the timing of a job change—and hence the need to apply for individual health insurance — is not necessarily something one can control. Thus, the time when a “pre-existing condition” starts to exist can be rather arbitrary.

Biologically, the propensity to develop many medical conditions exists from birth. Differences in DNA do increase or decrease our chances of getting a disease such as diabetes, heart disease, Alzheimer’s or breast cancer. Fortunately, the Genetic Information Nondiscrimination Act (GINA) has prevented discrimination by health insurers and employers since May 2008. Recent political discussion hasn’t included comments about pre-conditions written into our DNA, but the ACHA discussion and prospects for coming generations do prompt me to ponder what health care is for.

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In 2015, a Bloomberg report ranked 55 developed nations on health care efficiency—comparing life expectancy, health care costs per capita and costs as a percentage of GDP. The US fell near the bottom, at number 50. A 2012 report in the Journal of the American Medical Association asserted that waste—including unnecessary treatments, overpriced drugs and procedures and under-use of preventive care—makes up 34 percent of total US health care spending!

As former Surgeon General Vivek Murthy, MD, recently observed in a talk at San Francisco’s Commonwealth Club, no patient would opt for getting treated for a disease over avoiding the disease altogether. But our “health care system” routinely offers incentives that prioritize illness over health.

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The problem, I suspect, has to do with pre-existing conditions: 1) insurance companies (and big pharma) and 2) their outsized contributions to our elected officials. Since they get rich when we get sick, there’s little incentive for them to diagnose, let alone cure, the problem.

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