Preexisting Conditions: What Could Qualify as One, and Why It Matters

You might have a preexisting condition and not know it—and that could make a difference if the Supreme Court strikes down the Affordable Care Act.

The term 'preexisting conditions' has been in the headlines a lot this year, and that's bound to increase now that the Supreme Court has started hearing arguments about the Affordable Care Act (ACA). Here's everything you need to know about preexisting conditions: what they are, which conditions fall into this category, and what might happen to people who have one if the ACA is struck down.

What is a preexisting condition?

It's a health issue—such as diabetes, cancer, or arthritis—that you have or have had in the past, prior to the start of a new health insurance plan. If you were diagnosed with breast cancer 10 years ago, for instance, and you went shopping for new health insurance, your previous breast cancer would be considered a preexisting condition.

What counts as a preexisting condition, specifically?

Since a preexisting condition could be any health issue that existed prior to signing on to a new health insurance plan, a huge range of physical and mental health conditions could qualify. That can include epilepsy, diabetes, cancer, asthma, HIV, lupus, and sleep apnea. It can also include high blood pressure, high cholesterol, allergies, and even having an eating disorder. Prior to the ACA, your insurance company finds out if you have a preexisting condition when you sign up for new insurance and fill out an application, which asks you for your detailed medical history.

Some health-related symptoms and problems that aren't actual disorders or diseases can qualify as a preexisting condition. Pregnancy could be considered a preexisting condition. So could experiencing irregular periods or giving birth via a caesarean section. Postpartum depression would also be one. According to an analysis by the Department of Health and Human Services, 50-129 million non-elderly Americans have a preexisting condition.

Why do preexisting conditions matter?

Although they are not a major hurdle in the search for good health care today, preexisting conditions were an important consideration not too long ago. Prior to the enactment of the Affordable Care Act in 2010, insurance companies offering individual policies could decline to cover you, cover you with an exclusion for your preexisting condition, or hike your rates sky-high due to your health history.

If you had a condition (or even the risk factors for a condition) that might cost an insurance company a lot of money to cover your future treatment, it was difficult to find affordable individual coverage. "You personally could be discriminated against based on your health status and your health history," Karen Pollitz, senior fellow of health reform and private insurance at the Henry J. Kaiser Family Foundation, tells Health.

To get around that scenario, insurers also offered "skinny" plans with less coverage, such as a health insurance policy that didn't cover maternity care. "A lot of policies didn't cover mental health or rehab or drug treatment," says Pollitz. These skimpy policies had lower monthly premiums than more expansive plans. "So health insurance was cheap, as long as you didn't need it and didn't use it," explains Pollitz. "And it's not because insurers are nasty people—that's just the way a competitive, voluntary, unsubsidized health insurance market works."

Although preexisting conditions weren't as strong a factor in employer-provided health insurance, they still played a role in determining coverage. Before the ACA, workers who qualified for group health insurance might have to wait 12 months before the plan would cover preexisting health conditions.

This made it difficult for any person with a preexisting condition to purchase their own health insurance. Most people in the US get their health coverage through an employer or through a public program like Medicaid. But the individual insurance market is an option as well, and it typically caters to people who are self-employed, people with jobs that don't provide health benefits, and people who are between jobs. "Some people get coverage through that market for a long time," says Pollitz. "But most of the people who get coverage through this market are there transitionally."

How did the passing of the ACA affect preexisting conditions?

Under the ACA, an insurance plan can't reject you for coverage, charge you more, or refuse to pay for essential health benefits just because you have a preexisting condition. In part because ACA plans could not exclude people with preexisting conditions, more than 20 million more Americans were able to get health insurance coverage after the ACA went into effect.

Though the ACA has been around for years, preexisting conditions haven't entirely disappeared from the health care map. Short-term health insurance policies—expanded by the Trump administration—can still turn you down or exclude coverage for preexisting conditions. These plans fall outside the scope of the ACA, and many aren't true insurance policies but cost-sharing plans. "A report found that over three million people are signed up in those plans right now," says Pollitz. But if you're purchasing a plan from the ACA marketplace, you'll get coverage, no matter what your preexisting conditions are.

What will happen if the Affordable Care Act is struck down?

In the coming months, the Supreme Court is expected to make a decision about the constitutionality of one provision of the Affordable Care Act—and could, in turn, decide to invalidate the entire law. If that happens, the US could go back to a country that lacks the ACA health insurance marketplace. And in the midst of a major pandemic, that has health officials worried.

"If we turn back the clock now, we would allow insurance companies to once again block millions and millions of people with preexisting conditions from getting coverage." Leo Nissola, MD, a cancer immunotherapy scientist and medical advisor for COVID Act Now, a nonprofit organization that analyzes local coronavirus data, tells Health. "It's possible we're going to lose that, and that's the urgency that people in my field are trying to scream about."

It's also possible that a COVID-19 diagnosis could be considered a preexisting condition in some states and by some insurers—a diagnosis shared by more than 8.7 million Americans and counting. Even if the diagnosis itself doesn't qualify, so-called "long haulers"—those with COVID-19 symptoms that linger for weeks or months—or those who've received hospital care for COVID-19 might be denied coverage for any future treatment related to the disease.

"COVID cannot only damage your lungs, your heart, or your immune system," says Dr. Nissola. "It could make it linger for a long time, and that long-term damage to those vital organs could lead to an interpretation of COVID being a disease that the insurance companies would consider preexisting."

In the meantime, experts wait. "It's hard to speculate at this point about what the court might or might not do on this case," says Pollitz. "The range of decisions goes from throwing the case out to agreeing with the plaintiffs that the entire law is overturned—or something in between. We just don't know."

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