Mainers, here are the basics on pre-existing medical conditions

FILE PHOTO: U.S. House Speaker Paul Ryan (R-WI) speaks at a news conference in Washington, D.C. March 24, 2017.REUTERS/Yuri Gripas

Much of the fevered debate about House Republicans’ plan to replace the Affordable Care Act is coalescing around its implications for people with pre-existing conditions.

The term is insurance company jargon but it’s quickly becoming part of the popular lexicon. So what exactly does it mean, and how many people in Maine have one?

A pre-existing condition is basically a health issue that an individual already has at the time their health insurance coverage starts. Before the Affordable Care Act, in many states insurers could quiz you about whether you had at least one of these conditions through a process called (more insurance jargon here) “medical underwriting.” They could then use that information to charge you more or deny you coverage altogether.

Insurers in the individual market — where people who don’t get coverage through the government or work can shop for a plan — used to keep lists of pre-existing conditions that they would automatically deny. According to the Kaiser Family Foundation, these conditions included:

  • Cancer
  • Epilepsy
  • Kidney failure
  • Stroke
  • Severe obesity
  • Congestive heart failure
  • Pregnancy

(Some also kept lists of occupations that made a person ineligible for coverage, according to Kaiser. Those jobs included loggers, pilots, cab drivers, law enforcement, and, not kidding, “strong man competitors.”)

In Maine, more than 590,000 people have a pre-existing medical condition, according to U.S. Department of Health and Human Services estimates.

We’re a bit of an outlier in this department. Maine has prohibited medical underwriting since the 1990s, well before former President Barack Obama signed the ACA into law in 2010. We were among just a handful of states that banned the practice at that time.

There’s an important asterisk, however. If your coverage lapsed, insurers still had to issue you a new policy, but they could choose not to pay claims related to your pre-existing condition. So a pregnant woman, for example, could get insurance, but it wouldn’t pay for her prenatal care or the cost of the birth.

Source: Mayo Clinic

The Republican plan to replace the ACA, called the American Health Care Act, contains a similar provision. States could apply to the federal government for permission to let insurers consider a person’s health history when setting their monthly premium, if that person’s coverage has lapsed for more than 63 days.

(There are plenty of reasons why coverage can be interrupted — getting dropped from a spouse’s plan after a divorce, missing premium payments, moving, a billing mix up, etc.)

In Maine, insurers could dig through the previous year of your health history to look for evidence of a pre-existing condition. That included not only conditions that you received diagnosis and treatment for, but also any undiagnosed conditions causing symptoms any “prudent person” would see a doctor about.

Insurers got another opportunity to impose some restrictions when people tried to “buy-up” to more generous coverage, such as by adding a mental health benefit or getting a lower deductible.

Maine’s laws over insurance company practices were largely superseded by the ACA. But with congressional Republicans promising to grant more power to the states over health insurance regulation, Maine may end up revisiting them — regardless of the fate of the GOP’s current proposal.


Jackie Farwell

About Jackie Farwell

I'm the health editor for the Bangor Daily News, a Bangor native, a UMaine grad, and a weekend crossword warrior. I never get sick of writing about Maine people, geeking out over health care data, and finding new ways to help you stay well. I live in Gorham with my husband Nick and our hound dog Riley.