Who are the uninsured with pre-existing conditions in the US, and will they bankrupt health care

Great Debates
1

With the mandate taken out, and threads talking about how no enforcement existed anyway people are saying that now health insurance has to cover pre-existing conditions w/o a mandate that it will bankrupt the system.

But last year they were forced to cover children with pre-existing conditions as well as implement various other important reforms (end rescissions, cover kids until they are 26, end lifetime caps). I think the total cost of all of those was 1-3% higher health insurance premiums. But health insurance premiums have been going up 10-40% a year before that. So if forcing insurers to stop rescinding coverage, cover kids with pre-existing conditions and end lifetime caps only results in a 1-3% cost increase (far less than what happens in a normal year anyway) why would pre existing conditions for adults make such a huge difference?

http://www.healthreform.gov/newsroom/new_patients_bill_of_rights.html

Would the cost increases in 2014 when adults with pre-existing conditions get coverage honestly be anywhere near the regular 10-40% annual premium coverage people see anyway, or will it be another 1-3% spike like in 2010 when the other reforms started?

For that matter, who are the uninsured with pre-existing conditions among the 60 million total uninsured? The cultural stereotype is they are someone who developed cancer and needs 100k in chemotherapy. But I wouldn’t be surprised if 90% of them are people with conditions that can be managed fairly well for less than a few thousand dollars a year, if that.

I have pre-existing conditions, but my medications to control them cost less than $30 a year. I have heard numerous stories of other people saying the same thing. They have a chronic condition, they take generic medications that cost $50 a year and it is controlled. But they can’t get insurance because of it.

People over 65 are on medicare and most serious cardiovascular and cancer illnesses are among those 65 and older.

There are various state programs in many states for those with serious illnesses (high risk pools, maybe medicaid or other programs for sick adults, etc).

So those with truly expensive conditions seem like they are mostly taken out of the pool of uninsured.

So is opening health insurance up to those with pre-existing conditions really going to make a difference? I am guessing the jump in premiums will be a fraction of the 10-40% that will happen in 2014 anyway, even without the pre-existing condition law taking effect.
It seems the system is set to collapse anyway with radical premium increases, but the premium increases from the reforms put in by congress (ending pre existing conditions, ending rescissions, ending lifetime caps) may only be 5% or so, which is less than the jump that occurs in a normal year anyway.

2

How about someone with advanced AIDS? Suppose you have it, and are kept alive by a massive quantity of very expensive drugs. Your survival depends upon them-if you stop using them, you die.
This is an extreme example-but the same goes for chronic mental illness, or someone with a major birth defect.

3

Those people exist. And I could be totally wrong, but I am under the impression that there generally are programs for people like that already. So they wouldn’t be people new to the system who are just being added in in 2014. But I really have no idea what % of the uninsured are people with serious, expensive diseases and how many are people with a controlled, cheap to treat condition. Someone with AIDS that needs 10k a year in medical care has a pre-existing condition. But according to the definition of pre-existing condition so does someone who spends $5 a month on generic anti-hypertensives or anti-depressants that control their condition.

If covering people 0-19 with pre-existing conditions only raises rates (according to the government) less than 0.1%, and people 65+ have medicare, that only leaves those 20-64 with pre-existing conditions.

4

Until Sept. 1, I was an uninsured person who paid thousands of dollars every year for medical expenses, including about $3,000 for prescriptions alone. The reason was that I was self-employed with pre-existing conditions, and not poor enough for Medicaid, and there’s no insurance pool in my state. If I were younger, I’d be colliding with the system in 2014 at full-speed, instantaneously racking up huge medical expenses for the system. But since I’ve turned 65 and am now on Medicare, I’m taking care of those things now, at pre-2014 expenses. Contrary to the OP, there are a lot of us out there.

5

Let’s say all the unemployed get hired full time with benefits. Group insurance is not allowed to deny coverage for pre-existing conditions. Do the insurance companies go out of business?

Now let’s say that instead that those individuals are forced to buy health insurance. Same number of payers in both cases and same number of people with pre-existing conditions. How is that different than the above?

6

No, they’ve just increased the rates and reduced benefits on the existing members that have already been paying for their coverage for years :frowning:

7

I couldn’t tell you the number, but obviously the older you get the more likely you are to have a pre-existing condition. Hence we can expect it to cost more to add them into the system than kids.

Not wanting to pry into your own personal situation, but what would happen if you stopped taking your meds or didn’t follow the regime properly? More than half Americans admit to not taking their medicines properly.

Or possibly got immune to the drug and the alternatives are more expensive, or there is no alternative. Or the medication resulted in an expensive side-effect. Or the medication created an adverse reaction when taken with another drug.

There are thus several ways in which an apparently cheap condition could become a major expense later, and currently insurance companies would rather not take that risk.

8

Not to nitpicking that survey, but I didn’t see where it differentiated antipscycotics, antidepressants, pain killers and antibiotics… Any other stuff.

I was put on lots of Meds after surgery on my hand, and I didn’t follow my regime for Meds very closely at all. I took all the antibiotics, but I took the opiates when I damn well pleased, not twice a day. And I didn’t refill the bottle either, despite the fact that I could have (although I think I needed to call the doc first?).

Where would I count, having taken or not taken my Meds?

9

I don’t think the specific numbers or one example are particularly relevant. If we accept that a “significant number” of people do not take their meds properly, then that becomes an added risk for the insurers in taking on people with pre-existing conditions. As to the size of that risk, I do not know. I am just pointing out that the situation is not as simple as saying “this only costs $30/yr, so why will they not accept that?”

10

But how you define “significant number” is extremely important.

Are we saying people aren’t taking their antibiotics because they’re getting the squirts, or are we saying people aren’t taking (or abusing) their their opiates because they need to be able to drive (or want to abuse them)?

11

Will $290Bn worth do?

You are trying to drag this down into an unnecessary level of detail. I am not saying anything about any specific meds - just looking at the big picture.

12

I am almost one.

At 39 years old, I have the following pre-existing conditions: broken ankle, broken elbow, gallbladder removed for gallstones, appendix removed for what actually turned out to be scar tissue strangling my bowel, tonsils removed for cryptic tonsiloliths, multiple bouts of major depression, polycystic ovary syndrome, metabolic syndrome, pre-diabetes, benign heart arrhythmia, pre-hypertension, anxiety, obesity, ADHD inattentive, gluten intolerance, asthma, and now some unidentified auto-immune illness that will probably turn out to be mild Lupus.

Now, half of what I listed above no longer has any bearing on my health. I’m doing quite fine without my gallbladder, appendix, and tonsils. I’ve lost enough weight that I’m no longer morbidly obese or pre-diabetic, which significantly cuts down on the symptoms for metabolic syndrome. My blood pressure is ideal, and the medication to steady my heart arrhythmia has been on the market for 50+ years.

I still need to lose more weight, obviously. I stick to a gluten free diet, my PCOS is under control, and as I’m not married or rich, I will never pursue fertility treatments. My biggest problems are the bouts of major depression, the ADHD, and now, this new auto-immune problem.

I currently have health insurance. Out patient coverage tops out at $1000 per year, and in patient tops out at $50,000 a year. There is no prescription coverage, and I usually run through the $1K in the first three months. What saves me from outright bankruptcy - as I have to see a psychiatrist for depression and ADHD meds, a general practitioner for check ups and referrals, and now a rheumatologist - is that my insurance is still billed, they apply their discount, and then I’m responsible for what’s left. That’s usually about a third of the original bill.

My coverage is through COBRA and ends in May.

My current job does not offer health insurance, and the new auto-immune/possible lupus is causing me to miss so much work that my paychecks don’t amount to much. So, it’s harder to pay for medical care.

There is no way I will ever get an individual health plans. By the time I got to the third item, pretty much every single health insurance provider denied me outright. In order to qualify for the state high-risk pool, which will cost me about $650 a month or more, I have to be without insurance for six months.

Here’s what gets me:

While mild lupus usually does not progress, if it does, it could do extensive damage to my heart, lungs, kidneys, liver, and brain if it goes untreated. If I do not have insurance, I will not be able to get treated other than by walking into an ER and then declaring bankruptcy. Because it’s so difficult for me to afford treatment right now, I’ve lost about 50% of my work capacity. That’s 50% of my wages, 50% of the taxes I pay to support my country, and 50% of my ability to pay for the medical care I need.

It is completely possible that I will qualify for high-risk insurance and be unable to afford it. From what I’ve read of Medicare, I won’t qualify because while I’ll be dirt poor, I don’t have any children, and I don’t suffer from the conditions they cover. In that gap of coverage, without the treatment I need to keep lupus from progressively damaging my organs, I may end up completely disabled.

Then, I’ll be eligible for Social Security Disability Insurance, Medicaid, state disability, and all those other programs, but it will be too late for me to recover my ability to work, pay taxes, and contribute to my country. My SSDI will be less than $1K per month, so I’ll need Social Security Supplemental Income and other government welfare programs to afford housing, food, and other necessities. I will be a burden on my fellow taxpayers for the rest of my life, which will be shortened by more than a decade and crowded with extremely expensive medical care. Everything I could have contributed for the next thirty years as a healthy adult will be lost.

And all for the want of affordable health care now.

13

I don’t know, but I’ll add to the muddle.

A lot of people who would be denied insurance if they applied on their own already have coverage due to work or a spouse. Others don’t actually have excessive expenses. I have a family member who fits into both categories. He can’t get insurance on his own due to a major incident ~30 years. However, he’s been fortunate enough to be covered through work (or via COBRA while between jobs.) Even though the insurance companies would prefer not to have to deal with him, his health expenses over the past 30 years have been minor and largely unrelated to his condition. We were always scared when he was out of work because COBRA is expensive and could only be used for a limited time and under certain circumstances.

14

Perhaps such “programs” exist in some states, but there are no such “programs” which are widely available that I know of.

During debates o the Health Insurance Reform, I kept hearing people say, “Well, there are already programs for the poor, terminally ill, etc…”, just assuming this was the case.

As my late DH and I learned, there ARE no such programs, or IF there are, no-one would tell us what they were…we asked directly many times, of the SS people, the Medicaid/state insurance people, etc… He was uninsured, both because he had a preexisting condition (a genetic one) AND we couldn’t afford premiums anyway.

He applied for and was awarded full disability from SS his first try (practically unheard of). There was/is a 16 mth waiting period for Medicare/aid. He was dead by then.

As poor as we were, I was told we did NOT qualify for Medicaid and that in fact, ADULTS getting any such coverage was virtually impossible…kids, sure. Pregnant women/fetuses, all day long.

Our kids were and are covered by the state, but for adults to get on the plan? A lottery/waiting list (my name has been on it for 3 yrs and I just got selected).

We looked at every option we could, and there was jack shit. The sort of treatment he would have needed to extend his life by maybe a decade was NOT anything he could get at the ER…we’re talking open heart surgery, very costly drugs, other on-going, specialized treatment.

It’s a shocking realization that there is simply nothing out there for many people, and that if you cannot pay out of pocket or convince some specialist to work pro bono, you are shit out of luck. There is no “health care fairy”, as much as some prefer to believe there is.

He ended up going into the hospital to die, and the cost was passed on to those WITH insurance or who pay out of pocket.

As for “bankrupting health care”, we already spend a larger percentage of our GNP on health care than any other nation. One reason is that so many ARE unisured and rely on ER visits because they don’t make you pay up front. It’s much more costly to treat minor or chronic things at the ER than it is for them to be treated by a primary care Dr. It’s also far cheaper to treat things before they develop into an advanced form (and the person shows up at the ER).

All the costs which hospitals end up "eating"get passed on…they raise the costs of items and services to help balance the books, and that is passed on to patients who pay cash and to insurance companies who then pass it on to the policy holder.

Simply by covering everyone, we could save TRILLIONS of dollars a year.
And simply by eliminating for profit insurance from the equation (as most other nations who pay far less have) we could save even more.

Currently, these companies aren’t hurting…they are raking in record profits and jacking up rates many times the rate of inflation OR their actual costs every year. All this as they cherry pick customers, deny the sick or even potentially sick coverage and cap coverage for customers who GET sick. The reforms are a step in the right direction, but need to go further, imo. As in SINGLE PAYER.

15

Plenty of people wouldn’t even be more expensive, but do have pre-existing conditions that might keep them from getting insurance - my boyfriend can’t afford insurance, so we’ve never tested it, but as a child he had pretty bad asthma. He doesn’t have it anymore; he even runs now. I’ve always thought that was one of the things the insurance companies like to bring up to deny coverage, though.

Lots of people with pre-existing conditions probably have things like diabetes, which isn’t very expensive to manage if you’re getting the health care you need but is very expensive if you aren’t.

16

Why do you think they do that?

17

Uh, because they don’t like to do their job? There are plenty of stories of insurance companies dredging unrelated stuff up from your past as an excuse to deny you service in a completely unfair manner.

18

People with pre-existing conditions are less likely to be fully employed. They are more likely to lose their job due to their poor health.

There is a reason why some insurance companies spend over 20 cents of every dollar they take in to weed out the bad risks and to try and get rid of the sick people they have.

If an insurance company can get rid of its 1% most expensive policyholders every year, they would be ridiculously profitable.

The total premium for Blue Cross Blue Shield is between $13,000 and $15,000 every year; between $5000 and $7000 for individuals.

How much do you think the health care costs are for the median family or individual? The mean is significantly higher because of a slim minority of really sick people, so the insurance companies try to either avoid or get rid of those really sick people.

One of the only redeeming features of the new health care law is the medical expense ratio. Every health care company now has to pay out at least 85% of every premium dollar received in the form of medical expenses or they must refund the premiums to the policyholders. The fight in DC right now (quite under the radar), is what expenses count as medical expenses and what we ignore altogether. Kathleen Sebelius wants to limit medical expenses to stuff that the insurance company pays out in the form of benefits, the insurance companies argue that there are all sorts of internal expenses that should count as a medical expense (like doing underwriting checkups) or that should be excluded from the calculation altogether (like taxes). It reduces the incentive for insurance companies to screw over its policyholders.

19

Health insurance companies earn a huge fat margin on almost every policyholder they have. 99% of policyholders pay about $5000/year and use about $500-1000 of health care services per year. but there is a slim minority of policyholders that pay $5000/year but might cost $1,000,000/year. If they can avoid even half of these high costs insureds, the company becomes very profitable and all the executives get nice fat bonuses. In the process, they spend a lot of money weeding out the potential high cost insured and even more money trying to get rid of the high cost insureds. Its gruesome but as soon as health insurance companies became a for profit concern, this sort of stuff became inevitable.

20

Exactly. It is a business decision. Because the HI companies cannot reliably make a profit on the group of people with pre-existing conditions, these potential customers are declined.

I am for UHC myself, but criticizing insurance companies for being evil or just not wanting customers makes no sense (not talking about you, DA). Insurance companies need (profitable) customers. They are not going to turn people down for the sake of it. They turn them down because they cannot reliably make a profit from that type of customer (as a group).

It’s all very well to say that insurance companies should cover people with pre-existing conditions when it only costs a few dollars a year extra for their meds. If it were that simple, they would do it and make a healthy profit from those customers. Actuaries expert in their field know a lot more than random (but generally intelligent) posters to a message board.

The current system sucks big time, but it is what we have and any improvement has to start from here and acknowledge the reasons why things are. Hiding behind “HI companies are evil and stupid” will not help. I think we have to recognize that people with pre-existing conditions do genuinely pose a significant risk to insurance companies, and then work out how to deal with it.