Before he was diagnosed with head and neck cancer in 2015, Anthony Kinsey often went without health insurance. He is a contract lawyer working聽for staffing agencies on short-term projects in the Washington, D.C., area, and sometimes the 90-day waiting period for coverage through a staffing agency proved longer than the duration of his project, if coverage was offered at all.
When Kinsey, now 57, learned he had cancer, he was able to sign up for a plan with a $629 monthly premium because the agency he was working for offered group coverage that became effective almost immediately. The plan covered the $62,000 surgery to cut out the diseased bone and tissue on the left side of his face, as well as chemotherapy and radiation. His share of the treatment cost was聽$1,800.
If the , which聽the House recently passed, becomes law, people like Kinsey who have health problems might not fare so well trying to buy insurance after a lapse.
The Republican bill would still require insurers to offer coverage to everyone, including people聽who have preexisting medical conditions, such as diabetes, asthma or even cancer. But it would allow states to opt out of the federal health law鈥檚聽prohibition against charging sick people more than healthy ones. In those states, if people have a break in coverage of more than 63 days, insurers could charge them any price for coverage for approximately a year, effectively putting coverage out of reach for many sick people, analysts say. After a year, they would be charged a regular rate again.
Coming up with a figure for how many people have preexisting conditions that could put them at risk for facing unaffordable health insurance premiums has been the subject of debate, with estimates ranging from on the high end聽to on the low end.
What we know is that before the Affordable Care Act, known as Obamacare, insurers in the individual market frequently charged people more if they were sick. According to a 2009 survey of individual market insurers by America鈥檚 Health Insurance Plans, a trade group, 34 percent of coverage was offered at higher-than-standard rates, while 6 percent of those offers included waivers that excluded coverage for specific conditions.
But some health policy analysts suggest that it鈥檚 not only people who have a gap in coverage who could be affected if a state seeks the health law waiver. There could be consequences for anyone with a preexisting condition, even those who have maintained continuous insurance coverage. That鈥檚 because the bill opens the door for insurers to set rates for people based on their health. For example, those without a health condition could be offered discounted premiums.
鈥淚f you have a preexisting condition, you鈥檙e going to be put into the block of business with the sicker risk pool,鈥� said Sabrina Corlette, a research professor at Georgetown University鈥檚 Center on Health Insurance Reforms.
Requiring people to maintain continuous coverage is the Republicans鈥� preferred alternative to Obamacare鈥檚 individual mandate that requires people to have insurance or pay a fine. But there are many reasons people may have a gap in coverage, especially if they鈥檙e sick, say consumer advocates.
鈥淚f they鈥檙e diagnosed with cancer and going through a grueling treatment, they might move closer to their caregiver or the cancer center,鈥� said Kirsten Sloan, vice president for policy at the American Cancer Society Cancer Action Network. 鈥淭hey may quit their job for that reason, or they may lose their job.鈥�
Once people have a gap in coverage they may really be in a bind if the available coverage is unaffordable. To address this, the Republican bill requires states to set up a high-risk pool or reinsurance program or participate in a federal risk-sharing program.
State high-risk pools, which were before the ACA passed, have been widely criticized, however, as inadequate for people with expensive health care needs. Premiums were often extremely high, and there were frequently lifetime or annual limits on coverage. Some plans excluded coverage for as long as a year for the very conditions people needed insurance.
Still, Thomas Miller, a resident fellow at the American Enterprise Institute, says offer a reasonable solution for the 2 million to 4 million people in the individual market he estimates have preexisting conditions but would otherwise be medically uninsurable or offered such high-cost coverage that they couldn鈥檛 afford it. The that the bill sets aside to use for high-risk pools or other individual market activities, along with an additional $8 billion over five years for states that get waivers from ACA community-rating requirements, 鈥渃ould be adequate鈥� to meet the need, he said.
Besides, he argued, the higher rates would last for only a year.
鈥淥nce you鈥檝e paid up, you graduate back to the regular market,鈥� Miller said. 鈥淚t鈥檚 not like being sentenced to the Gulag.鈥�
Kinsey said he plans to keep his coverage up to date from now on, but he doesn鈥檛 think it鈥檚 fair to charge sick people higher rates even if they have a break in coverage.
鈥淚t would be problematic,鈥� he said. 鈥淚鈥檓 not in favor of that.鈥�
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