Between 36-122 Million Americans Have Pre-Existing Conditions That Would Restrict Health Insurance Coverage

Health insurance providers have a long history of telling individual policyholders — and people shopping for individual policies — that their care isn’t covered or their policy is voided because of a pre-existing condition. Starting in 2014, that is all supposed to stop when a condition of the Affordable Care Act kicks in, making it illegal for health insurers in the individual market to deny coverage, increase premiums, or restrict benefits because of a pre-existing condition. Question is: Just how many people are we talking about?

That’s why the federal calculator-heads at the Government Accountability Office recently undertook a study to look at which pre-existing conditions could put people on insurance providers’ Have Fun Paying The Hospital Bill Yourself List (a name we just made up but which we would not be shocked to find out is accurate), and what that means in terms of the U.S. population.

Since there is no set list of pre-existing conditions for which insurers will deny coverage, GAO rounded up those conditions that are most frequently associated with denied coverage, increased premiums or restricted benefits.

Topping that list is hypertension, which afflicts more than 33 million Americans between the ages of 19-64. That was followed by mental health disorders, diabetes, asthma, arthritis, COPD, cancer (excluding skin cancer). rheumatoid arthritis, heart attack, and stroke.

GAO then looked at five separate studies to estimate the possible range of Americans who have had a condition (not just limited to the above list) that could prevent them from receiving proper coverage.

Because each study looked at a different number of possible high-risk conditions, those studies demonstrate a wide range of results. On the low end, a study that only asked people about eight different pre-existing conditions comes up with an estimate of around 36 million people. Another study asked about more than 60 conditions and came up with 60 million affected Americans. Finally, the study that resulted in an estimate of 122 million people looked at 417 separate conditions considered to be chronic.

Of interest is that all the studies found that women are more likely to have a pre-existing condition, with anywhere from 21% to 72% of the female population affected (the midpoint is 37%). Meanwhile, 18% to 59% of males (28% midpoint value) may have a condition the insurance companies shake their heads at.

We doubt it will shock may people that the rate of pre-existing conditions also goes up dramatically once people hit their mid-50s. Between the ages of 55-64, anywhere from 43% to 84% of people (48% midpoint) are believed to have a chronic condition, a big increase over the 23% to 72% (midpoint 37%) range for people ages 45 to 54.

GAO notes that the groups reporting the lowest level of pre-existing conditions, are those who have individual insurance policies and those without any health insurance.

The report explains:

The lower reporting of pre-existing conditions among the uninsured, in part, may reflect the fact that they are less likely than the insured to receive timely preventive care and some common health problems such as hypertension and diabetes often go undetected without routine checkups. In addition, the uninsured are also less likely to have regular preventive care, including cancer screenings.

The lower reporting of pre-existing conditions among those with private individual insurance may be a reflection of the fact that insurers try to limit the number of people with pre-existing conditions that they accept into their plan.

You can expect these numbers to come into play by both sides of the health care debate. Defenders of the Affordable Care Act will likely say the data shows the sheer number of people who are going out-of-pocket (or not getting the care they need) if insurers are allowed to continue denying coverage for pre-existing conditions. Meanwhile, insurance companies can likewise point to the GAO study and use it to justify such policies, as they can not be expected to cover so many millions of unprofitable policyholders.

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  1. dwtomek says:

    Well that’s the shitty thing about our health care system. With the profit motive intact, they can’t be blamed for not taking on someones burdens that are already present. You wouldn’t be able to get a policy for your already sinking boat, the same applies to your body. I can’t wait to watch this whole system implode on itself.

    • TuxthePenguin says:

      Profit motive has absolutely nothing to do with the reason people with pre-existing conditions are denied coverage. It has absolutely everything to do with the fact that this is insurance – a hedge against future risk. It is an actuarial calculation based on what they know about you and the risks of certain things happening. If there were a true individual market, they’d get the information on you and do a specific calculation. They’d get an estimate that over the next 20 years, you’d cost them $X dollars. Then, to “cover” you, they’d want $X/240 per month. Notice that this model has no profit – its purely break-even (even a “non-profit” or governmental insurer is going to inflate it as it is all risk-based and to cover overhead). The reason true insurance works is that you have a large group to cover the pool in case that risk happens next month, rather than in five years.

      Now, if you had a pre-existing condition, some of those estimates change radically. They’d simply reprice and charge you based on the new calculation. Say you had a disease that required a prescription that cost $1k a month. Guess what… they’d raise your rate by $1k. Again, no profit motive. Simple insurance concepts. But all this assumes they can look at you – move it to group policies and they can’t before accepting your insurance. Some group policies do have bans, others don’t (and those cost more… those estimated costs are built in).

      How do you deal with pre-existing conditions? At that point its developed, its tough as any attempt to insurer it is essentially asking someone else to shoulder that burden. If you wanted to stay inside an insurance model, simply mandate that so long as a person has had insurance for the last year (or something) that they cannot be denied. Or a single payer. Or a “single payer” that covers those with pre-existing (ie, for everything not based on that pre-existing condition, the insurance covers. But for everything due to hypertension, Medicare pays, etc).

      Its a difficult discussion because, eventually, its a debate about limited resources. We could easily create a single payer system that covers everything and spares no expense. But we’d have nearly nothing else as it’d consume the vast majority of our taxes. But, in terms of insurance, profit motive has nothing to do with pre-existing coverage – its all about mathematics and statistics.

      • nishioka says:

        > But we’d have nearly nothing else as it’d consume the vast majority of our taxes.

        We are already past that point. OECD has our health care expenditure for 2009 pegged at $7,960 per capita. Tax Policy Center has $2.1 trillion for our tax receipts that year. That’s $6,885 per capita, unless I really botched my numbers.

        The problem is not who gets the money, the problem is how much money is involved. Procedures here cost a hell of a lot more than they do in other countries because there is no singular entity powerful enough to tell doctors “if you charge $1,500 for that MRI, nobody will reimburse you for it”. Or to tell drug companies they can’t game the patent system to keep generic manufacturers from competing with them.

        You can’t even dream of fixing health care until you solve this problem, IMO.

        • aerodawg says:

          Oh yeah, that’s exactly what we need. Price controls. That will do wonders for availability of care. I mean, all those cuts to medicaid reimbursement are the reason it’s so easy for medicaid users to find a doctor right?

          Wait, you mean it’s the exact opposite? Most doctors won’t accept less than what the care costs? Well that’s totally unacceptable.

      • Tacojelly says:

        “We could easily create a single payer system that covers everything and spares no expense. But we’d have nearly nothing else as it’d consume the vast majority of our taxes.”

        Two years ago, just out of college and recently laid off, I only made $14,000 between working a retail job and doing freelance work. I had to pay 3,000 (plus drug expenses) of that 14,000 for an uninsured hospital visit for a simple, yet still life saving procedure.

        I was fortunate enough to struggle through that (and had a bit of savings to soften the initial blow), but it’s instances like this that make me say; “damn the cost, we need a single payer system.”

        People should not have to avoid the hospital for fear of financial ruin. We should want to pride ourselves on quality of health in our fellow citizens.

        • VashTS says:

          Yep, most would probably agree with you. Except those rich and wealthy bastards who put wealth over the right thing to do. Is Capitalism evil, yes.

          Shame, I have a knee injury but no insurance to get it fixed. I actually avoided a doctor, just diagnosed from a friend who is in training, but was afraid of insurance companies finding out. My job sucks, I prepare for the future hoping like most Americans, wrongly so, everything will get better soon.

          But it will not unless, we overthrow the government. I know, too drastic, but voting and passing laws are never in the middle class or poor s’ favor. There is no other solution but anarchy.

        • Robert Nagel says:

          Would it not have been cheaper for you to buy insurance at $100 per month? You tossed and lost. You took the risk that you wouldn’t need insurance. Do you think you should be covered by someone else for free? If not, why didn’t you buy insurance? It doesn’t matter if it is single payer or not, you didn’t pay anything in you shouldn’t get anything out.

          • smartypants503 says:

            Individual health insurance plans don’t cost $100 bucks. At least ones that actually cover you with reasonable deductibles and copays. God forbid you are out of network as well.

            • Nigerian prince looking for business partner says:

              Very few plans cost $100/month, anywhere.

              The idea is that you get a high deductible and pay for everything out-of-pocket with the money you’re saving. With the HDHP, you gain access to in-network rates and can use pre-tax dollars (HSA) to pay for any treatment.

              We pay about $400/month to cover our family with a $10,000 HDHP.

              • icerabbit says:

                Ours just went up to $1250/mo for 2 adults 5k deductible per person. Going to a higher deductible per person didn’t add up. Save maybe two hundred dollars per month and end up with 10k deductible each.

                One medical event where you have to go to the hospital, you’re out several thousand dollars. We didn’t think it sane to spend 10k on insurance and then have a 10k deductible each.

          • icerabbit says:

            For a 40yr old a private policy with $5k deductible / year was $500+ last year, in my state.

        • aerodawg says:

          No what we need is actual insurance instead of the system of “cover everything” coverage that is in effect pre-paid medical care. The way we insure health care in this country is akin to buying “gasoline insurance” for your car. Raise your hand if you think that would just be cheaper than buying at the pump.

          I honestly don’t know what planet people live on, where they think they can pay a third party for their health care, who will then foot the actual bill to the provider for every single little thing and it will be cheaper than if they just paid the bill themselves.

          High deductible plans that are actual insurance coupled with health savings accounts coupled with reform of the medicaid system for the truly poor is the real answer…

          • Nigerian prince looking for business partner says:

            “No what we need is actual insurance instead of the system of “cover everything” coverage that is in effect pre-paid medical care.”

            It absolutely is!

            A Cadillac PPO is essentially a pre-paid medical saving’s account, with terrible returns, and you forfeit everything at the end of the year. There’s absolutely no point in spending $20,000/year to cover your family, in order to have $5 doctor’s visits. It only makes sense if you’re rich or a 3rd party is paying for the majority of the premium.

            In a way, it’s even worse than that because (if you’re in a non-group plan) you pay premiums with after-tax dollars, while medical expenses (HSA) are pre-tax.

            I’d much rather have a high deductible and pay for run-of-the-mill stuff out-of-pocket out of my HSA with the $10,000+ each year I’m saving in premiums.

        • damicatz says:

          “Damn the cost” is exactly why we don’t need a single-payer system. Healthcare isn’t free and making it seem like it is won’t fix anything.

          The problem with any “shared public resource” like universal healthcare is the classic problem of the “Tragedy of the Commons”, namely that people, when given access to a shared resource, will overexploit it even when it is against their own self-interest to do so.

          In the case of healthcare, making healthcare free means there is no motivation to not overuse medical services. Because healthcare is now “free”, people end up going to the doctor’s office for the most minor of ailments such as a mild cold or a hangnail. Invariably, this always results in rationing where people who actually need critical care are unable to get it in a timely manner. Just take a look at Sweden’s healthcare system : http://thecoldvoiceofreason.blogspot.com/2011/06/right-to-wait.html

          What needs to be done is to reign in the health insurance companies by eliminating their regulatory capture. They have bribed governments at all levels to institute policies favorable to them that allow them to manipulate the prices of healthcare services and create artificial scarcities that make basic healthcare unaffordable without insurance.

      • smartypants503 says:

        Sorry to burst your bubble, but health insurance companies can and do make a profit. If someone is denied coverage because of an exsisting condition it is due to the fact that they will cost the company too much money and therefore the company would not make a profit.

      • aerodawg says:

        You mean to tell me that insurance is a contractual assignment of risk and that if there’s a pre-existing condition, the risk is 100% and therefore the cost goes up? No way man!

        Here I thought I could go crash my car, sign up with Allstate after the fact and make them pay for it….

    • Tacojelly says:

      Yes. This is why, IMO anyway, the current Health care system is fundamentally flawed. Private companies need to make profit.

      Government shouldn’t be feared, it is a system that is supposed to work for the people it represents. I don’t see any difference in paying a tax in order to obtain health coverage and paying a company a fee for health coverage, except that a government system can be (ideally) more easily regulated to be altruistic and work for the public health at large.

      • Patriot says:

        The 9 scariest words in the English language according to Ronald Reagan. “I’m from the government and I’m here to help.”

    • tooluser says:

      Yay! This means healthy people will finally pay more! Finally pay their fair share!

      The super healthy 1% should be thrown in jail! They’re not doing their part! What about the 99%?

    • bluline says:

      So either I bankrupt my family or I die. Great choice.

    • bluline says:

      So either I bankrupt my family or I die. Great choice.

    • u1itn0w2day says:

      Excellent analogy, can’t get a policy for a sinking boat.

      The problem here is that the industry and patients want insurance to cover basic repairs on a non sinking boat. Insurance should be for a catastrophic event, not a routine one.

      • Jevia says:

        The thing is, you can bet that less than 50% of boats are going to sink, probably even less than 10%.

        But I’ll bet you $10,000 that more than 50% of Americans, if not more than 80% are going to get sick, are going to have either a heart condition or cancer, are going to have some sort of surgery in a hospital.

        You cannot “insure” health. It is a fact of life that humans get old, humans get sick. That’s why we should not have health “insurance”, we should just have health care.

        • pythonspam says:

          Except the insurance companies make their money from the 14 pounds of treatment rather than the pound of cure or the ounce of prevention (that and not actually covering the treatment and patients they claimed they would.)

        • icerabbit says:

          I’d be surprised if even 1% of boats sank.

      • Nigerian prince looking for business partner says:

        “Insurance should be for a catastrophic event, not a routine one.”

        Absolutely, that’s what insurance is for. The idea of insuring against every doctor’s visit and prescription only makes sense if a 3rd party is subsidizing premiums. We pay about $400/month for a $10,000 deductible and dump as much money as possible into our HSA. We pay for everything out-of-pocket but we’re still coming out ahead vs. our old insurance, where we were paying $1,000/month and still had a $5,000 deductible. A regular PPO with a low deductible costs close to $20,000/year in my state.

        I believe medical care should be made available to the poor but funneling it through private insurance makes absolutely no sense.

      • Kuri says:

        I’d be inclined to agree with you if a mere checkup didn’t close over $100

      • icerabbit says:

        Two problems there.

        The routine stuff is now also several hundreds of dollars, on top of a strapped budget for most people.

        As of next month the best option available to us is $1250/mo for catastrophic coverage, two healthy adults, $5k deductible per person per year.

        So, it isn’t like they’re giving catastrophic insurance away for a few hundred dollars while you can sock money away.

  2. gman863 says:

    No shit.

    If the words “bipolar” or “(pre)-diabetic” appear anywhere in your medical files, you’re screwed.

    In Texas, the only option is the state high-risk pool insurance (Blue Cross)at almost $400 per month.

    • Dagny Taggart says:

      $400 actually sounds pretty reasonable. My company pays almost that much per person for our group insurance.

    • icerabbit says:

      $400/mo is nothing. How about $1100/mo for two adults no preexisting, $5000 deductible each, individual policy, only major option in the state.

    • Nigerian prince looking for business partner says:

      $400 a month is really cheap. The national average for health insurance for an individual is in the ballpark of $7,000 – $10,000/year for a typical group PPO.

      • u1itn0w2day says:

        Cheap compared to other insurance plans, the optional preferred payment method of the health care industry. It is not cheap to someone in financial straits or doesn’t have a job.

    • icerabbit says:

      $400 with pre-existing / high risk is a bargain.

      Maybe we should move to Texas??

      In Maine as of next month it is now is $1250/mo for a private policy for 2 adults with a 5k deductible/year per person. Not high risk pool. Regular old policy.

  3. yossi says:

    very deceptive article, since the majority of people get insurance through an employer and most larger employers have not had pre existing clauses for decades.

    • dolemite says:

      Tying insurance to your employer was the 2nd biggest mistake we’ve made concerning healthcare in this country. The first was privatizing it in the first place.

      • Lisse24 says:

        1st really, since health care has always been a privately-run industry so we never really privitized it, just let it continue on being privately run. Most of the big problems with health care have come in when government tried to meddle.

        Now, obviously, in other countries we see that there can be publicly run health care that is well-managed and not a nightmare, but that’s not the way it evolved here.

        Planet Money, an NPR podcast, has some great episodes on health care, which are a must listen in order to get the background for what’s going on.

      • Robert Nagel says:

        During WWII there were wage controls to control inflation. Employers in need of employees could not compete on wage rates alone. The government allowed them to offer paid health insurance as an untaxed fringe benefit in order to get employees. After the war things went on as they had and the negative aspects were covered over for years and years.
        The lesson is that when ever government tries to solve a problem, in this case inflation, they cause another problem somewhere else. Perhaps government should try to do less.

    • FatLynn says:

      Very misleading comment. Even if you get insurance through your employer, if you can’t show insurance continuity, pre-existing conditions may not be covered until you’ve waited somewhere between 6 months to two years.

      • yossi says:

        Like I said, MOST larger employers have no pre existing clause. Take microsoft, apple, ebay, chase, citibank, bank of american, list the 2500 largest companies in american that probably accont for a majority of of employee, and 99% of them do not have a pre existing waiting period.

        • thezone says:

          Well actually you’re utterly wrong. Only half the people employed in the US work for companies with more than 500 employees. Those aren’t large corporations. And therefore MOST people aren’t receiving their healthcare through these largest companies.

          • OutPastPluto says:

            The pre-existing exemption probably exists for those smaller companies for the same reason. The industry is kind of incestuous and as long as you’ve had SOME kind of coverage before, you will likely not be left out in the cold.

            There are limits though. Of course those are being largely ignored.

            One of those is the fact that this “coverage continuity” does not apply when moving from one non-employer health plan to another non-employer health plan.

            Insurance being tied to your employer is no less socialist really than it being tied to the government.

            • thezone says:

              Sorry I worked for one of those “probably” companies and it was no not probably. The insurance companies do everything in their power to not pay for things. My family is currently covered through my wife’s hospital. On of our children got tubes in his ears. The doctor is covered. However, for some reason the audiologist he uses looks like she isn’t. We instantly call and spend multiple days talking to multiple people to finally get someone to “fix it”. I’m lucky I have a flexible job I can call during business hours (which is the only time you’re allowed to call). Many people just pay versus losing hours or vacation.

        • icerabbit says:

          Your math is so far off, it isn’t even funny …most people working for fortune companies. A few thousand employees here and there. LOL.

          And good one on the larger companies’ health care policies not having pre-existing exclusions.

    • gman863 says:

      Nice thought, until you open your own business (sole proprietorship, LLC) and your COBRA coverage runs out.

    • SecretAgentWoman says:

      Pardon me, but you are wrong.

      Employer insurance policies CAN and WILL deny coverage for pre-existing conditions for the first year of your policy, unless you can prove continuous coverage from a previous plan. Try going without your heart or diabetes treatments for a year.

      As a contractor without health coverage, yet I’m gainfully employed, I also think you are in denial of the sheer number of EMPLOYED people without health care coverage.

    • Gort42 says:

      Which is great until you are laid off.

    • smartypants503 says:

      Depends on the state. Depends on the policy. Depends on the company issuing the policy.

    • Jevia says:

      Which helps part-time, contract and temp employees, you know, the fastest growing “employed” demographic, how?

  4. parabola101 says:

    Life is a pre-existing condition… lived in France, Italy, & UK and never had to argue about getting a test OR treatment. Their health care system were the wonderful, particularly France.

    • The Twilight Clone says:

      But didn’t you have to wait 12-18 months for that test?

      /s

    • BennieHannah says:

      Hey I’ve got great, expensive US insurance, and I wait three months for a dermatology appointment with our PPO providers. And if they find anything I pay a good part out of pocket for testing. I also need a foot surgery that isn’t QUITE bad enough to guarantee coverage — so say the insurance gatekeepers who aren’t doctors and are only concerned with maximizing profits. Would I walk happier if I paid less and waited longer?

      • StarKillerX says:

        And do you think having the government run the healthcare system will really improve it’s efficiency?

        • Kuri says:

          I honestly think we;d break even there.

          • LabGnome says:

            Hehe. At this point I pretty much think we can’t possibly make it any worse.

            *Hears thunder in the distance.*

            Crap.

        • pythonspam says:

          Medicaid and Medicare spend more than 98% of their funding on actual patient care. Privately-run medicare may spend around 89% on care, where Private insurers spend only around 80% on patient care.
          You can’t claim government bureacrats are going to start rationing care, deny treatment, or institute death panels, because the companies already do that.

  5. Hungry Dog says:

    I don’t know why everyone is so obsessed with longevity. I’ve decided to go out the same way I came into this world, screaming and covered in blood.

  6. consumed says:

    I had my first run-in with this “pre-existing condition” garbage a few years ago.

    Because I had a back injury a few years ago and had a herniated disc, (when I was working at a small pharmaceutical company that had its own insurance and doctors) somehow that information was entered into a national database that United Healthcare looked up and was able to send me a nice little letter saying that they wouldn’t cover anything regarding that condition, because I hadn’t carried health insurance for a certain part of the previous year… Umm, yeah. I couldn’t keep a job because I was in severe pain all the time and could barely move due to my back problems.

    I really, really, really, HATE these damn profit-hungry insurance companies. This is the most corrupt and backwards system ever. I really have no choice in the matter other than to move out of the country!!!

    • jsweitz says:

      Delta’s ready when you are.

    • VashTS says:

      If you are serious, I too in all honestly thought of moving. The problem is gaining citizenship and worrying over job and language barrier.

    • yossi says:

      That is why the individual mandate is so important. Currently, healthy people can chose not to buy insurance, which is fine. but then someone who needs $50,000 in back surgery decides he will buy a medical policy for $300 a month and get upset that they dont want to cover the bills? If insurance companies were forced to accept everyone and every condition, they would go bankrups, because only sick people who needs hundreds of thousands of dollars worth of care would apply. Its no different than expecting geico to sell you a collision policy after you wreck your car.

    • icerabbit says:

      I argued for six months over a coding mistake which created a pre-existing condition nightmare. Was forced to pay … No escaping it or it would go to collections. Probably can still come back to haunt our family ten years later.

      • AustinTXProgrammer says:

        Collections can be kept at bay with a little bit of dillegence. No need to run from the big bad collection agencies. Most of them are dishonest so make them dot their i’s and cross their t’s. Of course that still leaves it on the provider, not exactly the correct end result.

    • tooluser says:

      Yes. Everything should be free. Everything is a right.

      Go buy me a sandwich!

    • Robert Nagel says:

      Who’s the greedy one. The insurance company that is trying to keep costs down for their policy holders or you who wants to get insurance for less than the probable cost of your bad back.
      I am troubled by your assertion that you didn’t pay for health insurance at a time that you must have had large costs due to the back injury. it doesn’t make sense. I don’t think you have given the entire story.

    • Nigerian prince looking for business partner says:

      The database is the Medical Information Bureau (MIB) and it is equivalent to a credit report on your health. Just like with credit, derogatory information should disappear off your report within 7 years. Just like credit, everyone should check their report once a year.

    • webweazel says:

      “send me a nice little letter saying that they wouldn’t cover anything regarding that condition, because I hadn’t carried health insurance for a certain part of the previous year”

      Try this one on for size: A relative had private insurance with BCBS. She moved to a different state and wanted to change her billing address/state of residence. They told her if she did, she would have to deal with the pre-existing conditions garbage. Irregardless that she did not have a drop in coverage over the past 5 or more years, nor was she switching companies. Just moving to a different state and letting them know. How does this compute?

  7. Ayla says:

    I feel this. Over growth of my lymph vessels at the age of 4, requiring surgery. Then at age 32 I tested a false positive on a cancer screening but that’s on my record forever now, just the positive part not the false part. *sigh* There’s no way I will ever be able to afford insurance, unless I win the lottery!

  8. thezone says:

    Hey don’t worry about it. You’ll get a voucher …. oh wait I’m being told that you only get the voucher if you survive to 65……my bad 67….72??? Really? Hey manual labor people as long as you survive that long you can use your voucher to try and afford the minimum health insurance program. Good Luck!

  9. Thyme for an edit button says:

    If it wasn’t for the Pre-Existing Condition Insurance Plan, I wouldn’t have had insurance at all last year (this year now have it through employer, whew).

    Conditions that got me rejected from plans I applied to: mitral valve prolapse, using anti-depressants for about 6 months in 2005, and seasonal allergies. Yep, seasonal allergies was a reason for rejection in one of the letters I got.

    • OutPastPluto says:

      Just in case you had any doubt about insurance companies being run by Ferengi that are there to make any excuse they can to NOT pay claims.

    • who? says:

      My wife got rejected from one plan because she had a shoulder injury 20 years ago.

      • frugalmom says:

        BCBS was willing to cover me, but nothing related to my congenital hip dysplasia would be covered. Nevermind that they paid for when it was fixed in 2005.

        Now I’ve been diagnosed with Sjogren’s syndrome. I will never be insurable again except through high-risk or group plans.

        • GirlWithGloves says:

          Can you apply for disability Medicaid in your state? Or even apply for SSI and look into Medicare for disability? In my state, people who do not receive SSI can apply for the disability Medicaid program but have a review done by the state on their medical records/condition to verify the disabling condition. If they have a high enough income, they can still get Medicaid but have to pay a spend down of medical expenses each month before the Medicaid kicks in for that month.

          I have lived with Rheumatoid Arthritis (aka Rheumatoid Autoimmune Disease) for almost 18 years, so I can understand the need and the worry for coverage. Also I’ve found that looking into the manufacturer of the medication that I’m prescribed, they often have some sort of prescription assistance program which can either fully pay or partially/mostly pay the cost of that medication. Abbott’s program for Humira reduced my copay to $5 per month. Contact/google those manufacturers for copay help! There is also needymeds.org for more prescription assistance information/programs.

          One last bit of advice, in regards to one horrible aspect/potential symptom development of these two similar diseases, check out Biotene products to preserve and help/improve/maintain dental/oral/gum health (especially Biotene Pbf mouth rinse). Doctors don’t seem to think to mention that particular impact on our health with these diseases much, if at all, and dental health is so important to overall health!

      • Pagan wants a +1 button says:

        I got rejected because my cholesterol test showed my bad cholesterol was One. Point. higher than is considered optimal. Seriously.

    • VashTS says:

      I am so sorry, I have no insurance so I feel your pain.

    • dolemite says:

      Years ago, at a checkup, I asked my doctor about my yellowish big toenail (it had gotten ripped off at one point and grew back all scraggy looking). He said it was fungus, and put me on Lamisil for a few weeks, which cleared up the nail.

      About a year later, I tried to get insurance. I was rejected. I thought it was because I was on Paxil for a year or so. Nope, it was the Lamisil.

      • Nigerian prince looking for business partner says:

        We ran into the same issue.

        It’s not the toe fungus that insurers are scared of, it’s the complications associated with the medication to treat it (liver). Aetna wont touch you if you’ve ever taken it but we had good luck with Highmark.

  10. NeverLetMeDown says:

    “GAO notes that the groups reporting the lowest level of pre-existing conditions, are those who have individual insurance policies and those without any health insurance.”

    One reason you don’t mention is adverse selection (or really the flip side of it): people who don’t have pre-existing conditions (i.e. healthy people) are less likely to seek out health insurance, since it doesn’t have the same value to them.

    This, of course, is a core problem in the individual insurance market – the more you think you’ll have high medical bills, the more likely you are to pursue insurance. If insurance companies can’t charge higher risk customers more, overall rates go up. When overall rates go up, the healthiest people with insurance say “hey, not worth it to me any more,” and drop it. So, the average person with insurance is now sicker, so rates need to go up, so more people drop out, etc. etc. etc.

  11. wordsmithy says:

    My family was bumped into the high-risk category because my teenage son was using a topical acne medication.

    Life is a pre-existing condition.

    • u1itn0w2day says:

      Exactly, shear and prolonged existance increases the chances of something developing or simply being detected that is actually the norm. How can someone get rid of their pre-existing condition if they can’t get treated or afford to pay for treatment since most treatments are priced on the concept of someone else is paying for it ie insurance.

      The health care industry wants a rigged game in their favor. They literally want to phone it in. Why have health care and medical schools at all since the most “healthy” will need very little care.

    • Eliamias says:

      Exactly this. I remember a story of a woman who had cancer who was dropped from her insurance when they found out she forgot to disclose an acne medication she took for some short period of time in her teens. That’s why I think the numbers presented are low.

  12. TasteyCat says:

    122 million Americans have chronic health conditions? 39% of the population?

    • Pagan wants a +1 button says:

      Sure. Anything that you’ll carry around for the rest of your life is considered “chronic”. GERD, Insomnia, Restless Legs Syndrome, even allergies.

      I’m actually surprised the number isn’t higher.

      • Nigerian prince looking for business partner says:

        I’m also surprised it isn’t higher.

        The term is incredibly vague, as is what constitutes a “pre-existing” condition. Having a C-Section or a woman just giving birth after 30 is considered a pre-existing condition to some insurers. As is allergies, fallen arches, or being diagnosed with toe fungus.

        We have non-group insurance and my wife is ineligible for maternity insurance (not that we could afford it anyways) because she had a C-Section. Thankfully, Highmark is pretty lenient with their HDHPs and we were able to get insurance despite of that ($10,000 deductible/$400 a month premium)

    • Yorick says:

      I broke a bone once. That’s a pre-existing condition. It healed completely but it could be used against me forever.

  13. VashTS says:

    Here’s the proper solution tax the rich properly, in fact back tax them and stop spending on weapons and stop corporate tax breaks that keeps, hold on trying not to laugh, that keeps companies in America rather than moving operations overseas..hahahhahaa…..whew.

    • DIRANONI says:

      35 largest U.S.-based multinational companies added jobs much faster than any other U.S. employers in the past two years, but nearly three-fourths of those jobs were overseas, according to a Wall Street Journal analysis….those especially need to be double taxed.

  14. sponica says:

    last I checked 1 in 3 women will test positive for HPV at some point in their life (most women fight off the infection and have no problem whatsoever), you know what is considered a pre-existing condition, an abnormal pap with HPV even when your doctor says “it’s low-grade, it just means come back next year”

    I’m not sure I agree with single-payer though…I’ve had too many clients at the VA have their MRIs rescheduled and pushed back a few months even though their joints are literally falling apart.

    and wasn’t there an article about the excessive wait times for mental health services at the VA just the other day? I know the VA isn’t truly single-payer as some vets have to pay the VA for services, but it IS government run healthcare…

  15. Hotscot says:

    Is this why my country, Scotland, and the majority of other developed countries’ health systems are superior?

    They cover everyone.

    If you didn’t already live under this system…would you actively chose it, given the choice?

    • Evil_Otto would rather pay taxes than make someone else rich says:

      I would, and lots of other people would, but lots of people have fallen prey to the “TAXES MUST NOT GO UP OR THE WORLD WILL END” trope.

      My employer and I collectively pay $1200 a month for health insurance. My taxes could go up $1200 a month and I would never feel it if things stayed the same. Difference is, everyone gets coverage under the ‘raise taxes’ plan.

      Then you get to the idiots spewing “Why should I pay for someone else’s coverage?” Breaking news, shithead: YOU ALREADY DO. This is just shuffling things around to make them more efficient and therefore save money. If someone without coverage has a problem, they go to the ER to get treatment. ER care is hugely expensive. Who do you think pays for it? The rest of us ALREADY DO through higher medical costs made necessary for the hospital to continue to provide care.

      Single payer is the only sensible system. Every other civilized country in the world seems to be able to handle it without imploding.

      • Nigerian prince looking for business partner says:

        Also, at least taxes are progressive in nature. Health insurance premiums are an incredibly regressive de facto tax. Last year, I was paying about $1,000/month (my employer threw in $300/month on top of that) for insurance with a $5,000 deductible.

        If you include insurance premiums, we have the highest taxed middle class in the world.

  16. Andy Dufresne says:

    Apparently the Consumerist is just interested in generating cheap page views by making statements about political controversies. I can get this garbage bickering elsewhere. See ya.

  17. vicissitude says:

    “Starting in 2014, that is all supposed to stop” Yeah right. If anyone actually thinks the political sellouts in the U.S. Supreme Court are not going to throw out the entire legislation, they’re kidding themselves. There’s no way on earth the Court’s Corrupt Corporate 5 are going to let this stand. Right now, I guarantee they’re working with lawyers and lobbyists from the health insurance industry, trying to figure out how best to word it. It’s a foregone conclusion, already bought and paid for, which just happens to be cheaper for them, than it is to cover pre-existing conditions. Enjoy your tea!

  18. chatterboxwriting says:

    I’ve just about had it with insurance companies at this point. I do understand that I am a bigger risk due to my pre-existing conditions (I was born with spina bifida, which led to my kidney disease which led to my hypertension), but I NEED coverage if I am going to live a decent life. I’ve been without for a few months and there have been a couple times where I thought I needed medical attention, but I did not want to go to the ER for fear of a huge bill.

    Insurance companies make no sense sometimes. Because of my health issues, I’ve been advised not to get pregnant — and that if I do get pregnant, I will have to spend a minimum of six months in a tertiary care facility due to the risk. I decided to get my tubes tied so I wouldn’t ever have to worry about it. The thing is, my insurance won’t pay for ANY contraceptive procedure. So they won’t pay about $15K for a tubal that would last me until after menopause, but they WOULD cover me if I had to spend six months in the hospital. Even if it was only $1,500/day total (which it wouldn’t be), that’s still $270,000. They’ll pay out $270K, but not $15K for a one-time procedure!

  19. dicobalt says:

    Still can’t understand why a roll of gauze costs $50 on my hospital bill…

    • u1itn0w2day says:

      Or $150 for 3 minutes with the doctor. That’s $3000 an hour. I’d rather suffer a disease than the massive effects of financial hardship will have on day to day survival.

  20. legolex says:

    Don’t tell anyone you get headaches, I was denied insurance coverage when I was 19 because I mistakenly answered yes when they asked if I got headaches. That was 10 years ago, I bet they’d hang up the phone on you now if you said that.

    • u1itn0w2day says:

      Those questionares for things like insurance or even a new doctor are not entirely for medical use. The policy makers for the insurance companies and the lawyers for the doctors love to mis-use information that should be intended for medical CARE. Most people will glady talk about themselves almost to the point of fault.

      Too many people are so anxious to ‘talk’ about themselves they answer yes to questions if they have the occassional issue and yet in reality those questionares should be for chronic conditions or repeat problems. Either way the patient is still trying to get medical CARE based on those questionares. They are they’re to have a problem solved/diagnosed.

      Tell about yourself(like I really care)-that’s the writer of those questionares.

    • Nigerian prince looking for business partner says:

      Which insurer?

  21. u1itn0w2day says:

    These statistics will prevail in a someone else is paying for it/profit driven health care system where the industry has voluntarily decided to base their treament on ‘insurance’. Same can be said for individual patients who have decided to obtain treament only if someone else is paying for ie insurance.

    As technology improves I’m sure there are/will be plenty of pre-existing conditions detected/noted. But there shouldn’t even be “pre-existing”. I thought the medical industry was there to treat ‘conditions.

  22. jbandsma says:

    Being born without a penis is considered a pre-existing condition that’ll get you denied. Or having acne as a teenager, a grandfather who had a heart attack (even though he lived to be 92), being too fat, or too thin, having a job…or not. The only ones that truly qualify for most insurance companies have been dead for a year or 2.

  23. Clevelandchick says:

    The point of insurance is a large risk pool – they are making their money on those 18-30 year olds who pay premiums but only use it for maybe a once a year check up or if they get a bad cold. These a-hole insurance companies expect us to believe before the first one of them got the bright idea of dumping policyholders when they get sick – they weren’t profitable and their profits weren’t more than sufficient. They sure as hell were. When they whine about profits now, they’re whining about not getting obscene profits and not being able to pay their CEO $100M in compensation.

    The insurance industry’s need for obscene profits drives up the cost of care. My brother is a general practice dentist, most insurance companies these days try to only pay him half the claim, meaning barely enough to cover his overhead. So he has no choice but to raise his fees so he can make enough money to pay his bills and support his family. He’s not rich, he drives an 8 yr old Toyota.

    Time to END anti-trust exemption for the health insurance industry and open up Medicare as a buy-in option for those who can’t get it at work or are self employed. At least w/Medicare I am not limited to the doctors in the PPO that dominates my region – I can got to whoever I want to.

  24. meniscus says:

    People who have pre-existing conditions are not eligible for insurance because they are inherently unprofitable and also they tend to buy insurance more.

    An insurance company isn’t making gamble on somebody who is sick. they have already lost. The Constitution prohibits taking so its illegal for the government to force a company to take someone who its going to lose money on. Better that they become unemployed and then its not so important. Once people turn 50 they stop spending and become useless dead weight, falling off the demographics.

    Big American corporations expect to make a huge profit margin on their investments per annum. The Wall Street dictates the efficiency cult.. Close profitable companies that treat employees well, because they aren’t profitable enough!

    Insurance companies are the most profitable because of ERISA Section 514 which allows them to keep denying more and more care, gradually lowering the standard of care legally.

    So, money they take in is increasingly FREE money. Just for insulating politicians from any actual responsibility.

    So, we just can’t win. The insurance compaanies won and Americans lost this battle so very long ago, we just can’t admit it. (There is a news embargo, FAIR.org says, on stories about single-payer, because its always TOO popular a subject)

    Imagine you started an insurance company of last resort, that insured anybody, even the sick. You would have to either limit the amount of coverage you gave people to make it almost worthless, and most important, figure out some way to dump you if you got really sick, OR you would have to charge SO much that only the richest (and typically, the healthiest) people could afford it. The people you want to avoid are the poor people, everyone over 40, and the sick.

    Google “Adverse Selection” or “Insurance Death Spiral”

    Obama’s “plan” isn’t going to work, and nobody expects it to. Because of “death spiral” it can’t. Its just a sneaky way of keeping those really big bucks rolling in a bit longer.

    America SHOULD just do away with insurance altogether, which would also have the advnatage of being WTO-legal because it doesn’t discriminate against multinationals YET..

    To do that we would have to make all doctors in network, period. That is absolutely essential to stop the shift towards a defacto caste system.

    So, make it illegal for doctors to treat anybody better than anybody else for money. Cover everybody, so people don’t lose their insurance when they get sick and can’t pay, pay for it all with taxes, (which we almost do already, because as I said, insurance companies have developed dumping sick people to a science) The net cost wouldn’t rise, it would fall. A lot.

    But, then, (DAMN, companies would have to give up on that great, LEGAL EXCUSE to lay people off once they pass 40, so young people might have a harder time getting jobs, just as older people could stay employed longer.

    And they would have to continue paying those overpaid older workers salaries a bit longer.

    Just kidding!

    The fact is that the health insurance model that America uses is completely broken. And our healthcare is increasingly an embarrassment, the global poster child for dysfunction and injustice. But we are trapped into it because of our WTO stance.

    It wouldn’t “look good” to some if the US, the bastion of free trade and lasseiz-faire capitalism, started giving its citizens a sweetheart deal when we forced so many other nations to forgo similar changes in their countries for free trade. But, it would BE good for America.