Patients with Pre-Existing Conditions at Risk Again if Republicans Overturn ACA?

Insurance coverage might become unaffordable for some of New Jersey’s most vulnerable residents

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The number of Americans with pre-existing medical conditions who lack health insurance declined 22 percent after the national health reforms under the Affordable Care Act took full effect. These patients could have a tougher time securing effective, affordable insurance coverage if the ACA is overturned, according to a federal government analysis.

A report released Thursday by the U.S. Department of Health and Human Services noted that at least 61 million people under age 65 — including 1.2 million in New Jersey — reported chronic health conditions in 2015 that could have made it difficult to obtain care if the ACA wasn’t in place. The law required insurance plans to offer coverage to new patients regardless of their medical history.

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Without the ACA’s protections these individuals, suffering from high blood pressure, behavioral health issues, diabetes, pulmonary problems and other chronic conditions, would likely struggle to find new coverage if they were forced to change plans, the analysis suggested. And while New Jersey law and federal guidelines offer additional protections for those with prior conditions, a post-ACA landscape could lead to unaffordable coverage for some of the most vulnerable state residents, while further destabilizing the insurance market and driving up costs system-wide, experts warned.

With Congressional Republicans and President-elect Donald Trump eager to overhaul the controversial law, the administration of President Barack Obama — the plan’s architect — has worked hard in recent weeks to showcase the ACA’s benefits. They have highlighted how the measure extended insurance protection to more than 20 million low-income Americans —including nearly 700,000 in New Jersey — and how regulatory reforms ensure patients now have free wellness and preventive care, can stay on their parents’ plan until age 26, and don’t face lifetime limits on their insurance benefits.

Thursday’s report focused on another highly popular element of the reform, the “protection guarantee,” which the DHHS said enabled some 3.6 million non-seniors with pre-existing conditions to obtain coverage that would likely have been out of reach in the past. The findings are based largely on data collected by the Kaiser Family Foundation between 2010 and 2015, and published in December, and don’t reflect the total impact of the law, which was adopted in 2010 and fully implemented by 2014.

“Nonetheless, this initial snapshot confirms that the ACA’s insurance market reforms are providing important protections to the up to half of Americans whose medical history previously put them at risk of being denied access to affordable health care,” wrote the DHHS Office of the Assistant Secretary for Planning and Evaluation, which compiled the report.

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While high blood pressure, behavioral health issues, and pulmonary concerns are among the most common pre-existing conditions, the Kaiser Family Foundation found that — in the past — patients have also been denied coverage for arthritis, epilepsy, Lupus, paralysis, and pregnancy. Not surprisingly, prior conditions are far more common among older individuals; 84 percent of those aged 55 to 64 have at least one issue that could be a concern.

“It’s a big issue, but it might not be quite as big as they’re describing,” said Ray Castro, a healthcare analyst with New Jersey Policy Perspective, who has raised concerns about the impact of repealing the ACA. Castro noted that many patients with pre-existing conditions are already covered by large-group policies that pay for their treatments, something the Kaiser Family Foundation also found.

“But if those people lost their health insurance, and had to go to the private market, that’s where the problem would be,” Castro added. Regardless of individual price protections, the higher costs of caring for these patients would drive up costs overall, he said, noting that before the ACA reform some people with chronic conditions faced premiums that cost tens of thousands of dollars each year. Given the evolving economy, people are more likely to face insurance changes in the future.

The New Jersey landscape is further complicated by a longstanding state law designed to protect vulnerable patients. Health insurance carriers here are required to issue coverage to individuals or small businesses regardless of the health status of patients. The measure also seeks to control premium costs for those with prior conditions, but it involved a yearlong delay on coverage for related treatments for some patients. (This delay was erased by the ACA, but patients can still face coverage gaps if they miss the annual enrollment window, experts said.)

“New Jersey went further in regulating access than just about any other state,” said Ward Sanders, president and CEO of the New Jersey Association of Health Plans, which represents the state’s major insurance carriers. “But guaranteed access did not ensure affordability. That has been and remains our key challenge.”

Castro agreed, noting that New Jersey has “all these great standards” but no way to ensure the insurance pool is balanced with healthy, less costly members. Before the ACA, the individual insurance market “costs got so expensive it went into a death spiral,” he added.

The ACA sought to achieve this balance with the most controversial element, the mandate that required those who could afford coverage to purchase a plan or pay a tax penalty. And, as the DHHS report underscored, that piece is critical to any success. “Prior to the Affordable Care Act, states that tried to protect people with pre-existing conditions without other measures such as financial assistance and an individual responsibility requirement saw premiums skyrocket as not enough healthy people entered the risk pool,” the report noted.

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