Je suis Charlie

Let’s talk about preexisting conditions. Like the Farmer’s insurance ad series, I know a thing or two about that. I have been reporting underwriting evaluations for decades for patients looking for life insurance. And before the Affordable Care Act, I was doing it just as much for patients wanting new health insurance when individual underwriting was the norm for those people not eligible for group insurance.

Individual Underwriting Blocks Real Insurance

What an awful time that was. People were routinely denied health insurance for “preexisting conditions” that were truly common. Try low back pain, or high blood pressure that had been controlled for 20 years, or irritable bowel issues, or, God forbid, a self-limited episode of situational depression after death of a close relative. If the insurance wasn’t denied outright, the person was “rated” and required to pay much higher premiums.

So the hypertensive patient might get insurance at double or more the cost but would not be covered for hypertension office visits or anything that could possibly relate to that. Such related conditions would extend to heart attack, strokes, kidney disease, and headaches. Push come to shove, and the insurer had the ability to and frequently did deny coverage for pretty much any biological condition vaguely related to the cardiovascular system. What a joke.

Is Health Care a Right or a Privilege?

The real argument is whether real health care is the right of every individual of whatever means, or whether it is a privilege and at some level only those with the capability to pay for health care should get it. Once you inject preexisting conditions into the access equation for health care, the enormous rise in rates that will occur for those with a wide range of common human ailments in midlife and later will effectively mean many of those people will not be able to afford health insurance and will not actually get health care. To me, that is inhumane and inconsistent with who we Americans are as a people.

I am unconflicted: Every person should be able to access and receive competent health services with health insurance regardless of their economic status. That means Medicaid and subsidized insurance for a substantial portion of our population as it is under the Affordable Care Act, and as is true in most of the developed world, as well as employer-provided health insurance for the employed and Medicare for the older generation. Or even better, a universal single-payer system that covered everyone, perhaps modeled on Medicare. But that is another discussion.

Could You Personally Be in Trouble With Health Insurance? Yes.

If the current Republican (“American Health Care Act”) measure just passed in the House gets into law, everyone over 50 reading this who is not on Medicare could conceivably be at risk. How? Simply, lose your job or get between positions for longer than Cobra coverage allows, and you might have to apply for new individual health insurance. You would be underwritten. Then those innocent and often perfectly controllable conditions for which you might see me a few times a year disqualify you or result in dramatically higher premiums — read high blood pressure, mild diabetes, some arthritis in the knees, any kind of cancer even that successfully treated, any significant depression or emotional disorder, heaven forbid anything serious requiring continuing treatment like multiple sclerosis, or sleep apnea, asthma, or severe overweight.

While you may have read some estimates suggesting that “only” one third (33%) of people under 65 would be adversely affected by preexisting medical conditions, I believe the number is vastly higher. Based on my years of underwriting and detailed knowledge of my patients’ diagnoses, medications and occupations that historically led to preexisting condition exclusions, my personal estimate is that fully two-thirds (67%) of you would be denied coverage or rated if preexisting conditions are allowed back in the picture.

We Are All Preexisting Conditions

To be human older than 50 is to be a preexisting condition. The abolition of preexisting conditions and underwriting for health insurance, as accomplished under the Affordable Care Act, was a milestone in our evolution. It took the terror out of health insurance. The proposed Republican legislation (the AHCA) takes us back to the dark ages of underwriting. I was there. It was awful. We can’t go back. Remember Charlie Hebdo. We are all preexisting conditions.



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2 Responses to We Are All Preexisting Conditions

  1. Tom Myers says:

    Dr Kanner, you are more right than wrong, but wrong nonetheless.

    You are looking at the individual and not the herd. You trust doctors (who only see the sick and anxious well) but distrust actuaries (who see the cost of a few individuals on the cost to everyone).

    Imagine the most common disease–sex. (No I’m not implying that “lovemaking” is a disease, but there’s a complex of health concerns associated with the Y chromosome.)

    Men do not live as long as women. Who knows why, but it’s indisputable. That means, by your logic, that sex (an admitted pre-existing condition for any insurance) should not affect premiums. In life insurance sex affects premiums–women’s premiums are less. In car insurance sex affects premiums–women’s premiums are less. I’m uncertain whether women pay lower insurance premiums for homeowners’ or renters’ insurance.

    Can we look to see whether women have different health costs than men? Apparently no.

    Age is another pre-existing condition. Young drivers (under 25 or so) pay more if their parents even allow them to drive at all. Older drivers (over 85 or so) have more accidents until their children don’t allow them to drive any more. Young people and very old people pay higher auto insurance premiums than “the rest of us.”

    Can we look at age to see if young people’s healthcare costs more or less than old people? YES! We can! However we can’t let the ratio of young premiums slip to less than 33% of an old person’s premium. Actuarially a 10 to one ratio is about right.

    As an old person, I delight in the fact that these oh-too-eager whippersnappers are forced to pay high premiums so I can pay low ones and listen to my recordplayer.

    Very fat people, very tall people, etc all have adverse healthcare differentials. We cannot shame or “discriminate” against these folks. We can note that Presidents live to remarkably old ages, but NFL linemen do not. If a life insurance underwriter can use this information, why can’t a health insurance underwriter.

    During WW II, the US government chose to fixed wages. Since they were buying half of all the output of the economy, the last thing they needed was to pay a higher price for scarce labor caused by the government drafting men and sending them to war. To compete, business began to offer “benefits” like health insurance to groups workers. This was seen as a nice plus and it survived that war and a few more since. For simplicity’s sake, the group was treated like a “family” that paid the same for insurance–independent of sex, age, height, weight, smoking habits. This was clearly a rip-off for half of any group–a huge rip-off for the non-smoking young man of average height and weight. He couldn’t complain much because most of his peers were getting shot at.

    After the war the benefit remained. The insurance companies (originally only BCBS) didn’t do much underwriting in the “group” market. The cost of medical care was low and the cost of underwriting individuals was high. The underwriters made a pact (that you know about and gloss over): if you left one plan and went, more or less immediately, to another plan you weren’t underwritten. You were treated as a “normal risk” in a new family. If you slipped out of the system, you’d be underwritten to keep your new employer and new “family” from having to take on the rare, unusually high risk. You don’t expect life insurers to insure the newly dead, or auto insurers to insure wrecked cars, or home insurers to insure burning houses. How can insurers insure people with unaffordable conditions? If they are forced to, won’t healthy people want an alternative for lower price, higher quality, or both?

    A friend’s brother recently needed a heart and lung transplant. He had quit his job a year earlier to move to Florida for better weather than upstate New York. Despite all the pharmacist wanted signs at CVS, Walgreen’s, Publix, etc he never got around to getting a job and joining a new group. When his diagnosis came, he was thoroughly “uninsured.” Now who was going to pay for his operation and years of drug therapy? Not him, certainly. His thought, “Uncle Sam. He pays for these things.” Alas no. Uncle Sam has a soft spot for old people and poor people but not for sick people, per se. (Treating sick Americans like the government treats the old Americans and poor Americans would cost $35-50 trillion.) He needed the operation as soon as possible so he signed up for MedicAid hoping that they’s not notice that he wasn’t poor. He got his operation. Unfortunately an observant civil servant noticed he was the only “poor” person in an affluent suburb of Tampa. He got a bill (and some nasty talk about potential criminal charges). He couldn’t pay the bill–no normal person could. He needed to pay for expensive meds. My friend, ironically a wealthy insurance executive, went back to the doctors and hospital and negotiated lower prices (like the federal government and insurance companies pay) and then promptly paid them.

    His brother is now a “loudmouth”–ungrateful for his brother’s skill, time, and money; for the kindness of the hospital and doctors; and the forbearance of the federal prosecutors. He agrees with Dr Kanner that health insurance (unlike housing, clothing, or food–huh?) is a “human
    right.” Despite a lifetime of smoking and overeating, he points to other fat smokers and says he is a victim of bad luck not bad choices. Now, he cannot work as a pharmacist and he will not work as anything else.

    Dr Kanner and I always differ on such topics. Here I wonder how a man who makes his living selling healthcare thinks healthcare is a right–along with the right to vote, the right to assembly, the right to speak your mind, the right to a trial with a jury of your peers–none of which cost one-sixth of the output of the US economy–roughly the total of all taxes during the decade. What if access to apples, peaches, and apricots were a right? Would he still grow them if they generated no revenue and were available at roadside stands for free? I suspect many doctors will leave if the profession devolves into something like an HMO funded by the Post Office and run by the RMV.

    The other area where I think even he will agree he’s wrong is on the math of 1/3 or 2/3. Dr Kanner see patients–not non-patients. He sees the sick and the anxious well. If he spent more time at the gym or on bike paths or in stores and restaurants or in other offices, he’d notice that we are not so sick or anxious as his patients are. We also understand that we shouldn’t quit our jobs until we have another job on the line. (My mother taught me that and it kept me from quitting in a temporary snit.) The 1/3 is scary enough.

    However, all of that said, the argument on pre-existing conditions is lost by us “good guys.” The only choice for the vast population of healthy Americans is between paying significantly more for those who don’t take healthcare seriously, or to, like Dr Kanner’s patients, leave the “public” market and go to the “private” market. Income inequality begets healthcare inequality. The rich will opt out and pay for premium healthcare–just like in every developed country. In the US, as in Canada, England, Holland, and many other countries, great healthcare will not be affordable by over 90% of the population (as now), but only by 5-10%. Glad Dr Kanner and I are in the to 5-10%.

    • DrKanner says:

      Tom has written a thought-provoking and substantive piece on health insurance, illness, self-care and responsibility and related topics. This is immensely complicated, as is most everything in the health field. I would stand by my belief that everyone is entitled to health care. I think that is a simple and correct precept. But the immediate consequences of who pays and how much are not the same issue and are much tougher. These are all worth fighting about and many answers compete. The Affordable Care Act, requiring everyone to participate, including the young who use little care, and subsidizing the low-income folks who can afford some but not all the bill, was a rationale approach to paying the bills that flow from the right to health care. If the current administration succeeds in torpedoing the mandate and subsidy portions of the ACA, then that payment solution will fail and real people will suffer without care.

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