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The hidden rules of America's health insurance: Why some patients are turned away?
In the U.S. health insurance system, "pre-existing conditions" refer to medical conditions that existed before health insurance took effect. According to U.S. health insurance policies, until 2014, some insurance plans would deny coverage for a patient's required medical expenses due to pre-existing conditions. Behind this practice, insurance companies are trying to deal with adverse selection from potential policyholders, and these exclusions are prohibited by the Patient Protection and Affordable Care Act after January 1, 2014.
“Pre-existing condition exclusions are effectively like health insurance ‘allocations.’”
According to the Kaiser Family Foundation, in 2016, approximately 52 million adults under the age of 65 had a pre-existing condition. And the standards for how to define a pre-existing condition also vary among states—some states require insurers to use an "objective standard," while others use a "prudent person standard."
Current regulations for health insurance
With the passage of the Patient Protection and Affordable Care Act, pre-existing condition exclusions have been banned across the board. The Act came into effect in March 2010 and implemented a series of key reform measures in the subsequent period. Here are a few highlights:
- A national high-risk pool is established for individuals with pre-existing conditions who have been uninsured within the past six months.
- Pre-existing condition exclusions for children under 19 are prohibited.
- Effective January 1, 2014, all health insurance plans may not include pre-existing condition exclusions.
Further investigation revealed that in some cases, insurance companies would treat domestic violence as a pre-existing condition, which triggered widespread concern and criticism from all walks of life.
“The practices of some insurance companies are undoubtedly pushing victims into greater danger.”
Past Norms
Prior to 1996, pre-existing condition exclusions were mostly left up to each state. Although some basic restrictions began to be implemented with the passage of the Health Insurance Portability and Accountability Act, policyholders in many states still face stringent conditions and high premiums due to legal differences between states.
Insurance Company’s Position
Many believe that insurance companies exploit these provisions to maximize their profits, even at the expense of the physical safety of domestic violence victims. Supporters of continuing pre-existing conditions say it would lower the cost of health insurance and make it easier for others to get coverage.
"Insurance companies want to charge high premiums without taking on any risk."
Controversies over regulations
Political views on this issue are also clearly divided. According to multiple polls, 80% of Americans support insurance companies protecting the rights of people with pre-existing conditions. Although there are different voices and positions, the end result is that most people want to see increased patient protection in the insurance industry.
Finally, the debate triggered by the pre-existing condition clause is not only a legal issue, but also a discussion about human rights and medical fairness. So in this policy context, who is the real protected object?
