Pre-X Redux

With the focus now mainly on exchanges, Medicaid expansions, and enrolling the uninsured in newly available coverage arrangements, there is less attention lately to the ACA insurance reforms which have always been the most popular parts of the law – changes which could affect every American’s insurance in some way and which go into effect regardless of the implementation decisions states make.  In this column, I draw on our recent tracking polls to review where the public stands on the most prominent of these insurance reforms – guaranteed issue. This is another area where information could matter because many people with pre-existing medical conditions who stand to benefit from the law don’t seem to know about it.

Forty-nine percent of the American people under the age of 65 report that they or a family member have a pre-existing medical condition such as heart disease, diabetes, asthma, and cancer. Among this group, a quarter (25%) say that they or someone in their household has been denied coverage or had their premium raised because of a pre-existing condition.

Thirty-five percent say they worry that they will have to pass up a job opportunity or forego retirement plans to maintain coverage and nearly one in ten (9%) say they or someone in their household has passed up a job opportunity or decided not to retire in the past year because of “job lock”.

The “guaranteed issue” requirement in the ACA fixes this problem, which is called medical underwriting. It requires insurers to issue health plans to anyone in the individual or group markets, regardless of their health status, and prohibits rate surcharges based on health status in the individual and small group markets.  Like most of the ACA’s major revisions, it kicks in January 1 of next year, with open enrollment beginning this October.

The provision is popular; 66% of the American people support it. It is also one of those ACA provisions Republicans like, with 56% of Republicans supporting it. The President has talked about it often, journalists have publicized it, and experts have debated the impact of eliminating medical underwriting on the costs of insurance since passage of the law.  But like many elements of Obamacare, many people who will benefit from it don’t seem to know about it. Among those who report that someone in their household has a pre-existing condition, four in ten are not aware of the guaranteed issue provision. Just like the other group who will benefit most from the ACA, the uninsured, a large number – in this case half of all people who have someone in their household with a pre-existing condition – say they don’t have enough information about the ACA to know how it will impact them or their family.

Not everyone with a pre-existing condition has had a problem getting health insurance. People with employer-based coverage are protected under the previous law unless they lose their job and experience a coverage gap. Nor does liking the idea of guaranteed issue necessarily mean someone will support the ACA; people like or dislike the ACA for various reasons. And, there are tradeoffs in eliminating underwriting against people with pre-existing conditions. Premiums may rise somewhat to accommodate coverage for people who are sick (the idea is to balance this to some extent by insuring people who are young and healthy as well).

But there is a large constituency of people with major illnesses who will benefit from the law who do not seem to know it, and virtually everyone benefits from the peace of mind of knowing that if they get sick they no longer can be denied coverage or priced out by surcharges, even if they have large group coverage and lose it. Right now, working people who get sick and need to leave their jobs have only expensive COBRA coverage as a temporary solution.

The ACA awareness and outreach effort now getting underway is aimed more at the goal of connecting the uninsured to new coverage opportunities than helping people to understand the security of knowing that they can’t be denied coverage if they get sick. There is obvious logic in that, since the law cannot succeed without getting people enrolled. But, many people with pre-existing conditions such as cancer, heart disease, or diabetes are represented by organized and usually very effective disease groups. They have a role to play in informing their constituents about this issue as do health professionals whose patients may benefit from the guaranteed issue provision. Fifteen percent of those with a pre-existing condition say they have talked with their doctor or a medical professional about the ACA.

One reason this is important now: as the economy improves, people will be looking for better job opportunities, and there is a significant group of people still afraid to change jobs because they are sick and who seem not to know that they soon will not have to worry about that anymore.


(Note: In this column, I report data on pre-existing conditions from our March, April and June 2013 Kaiser Tracking Polls and our September 2011 Tracking Poll. I focus on the non-elderly because seniors are protected from medical underwriting by the Medicare program.)

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