Written By: Dr Cheryl Anderson, Online Health Care Management Program Chair
We are all eagerly perched in the front row of national political debates that include discussions on health policy. Most health care administrators are keenly watching each word uttered by political candidates about anything related to health policy change. One of the most confrontational discussions seems to be surrounding “pre-existing conditions.” The phrase is thrown around frequently. However, many people are perplexed by the term and its application.
Pre-existing conditions refers to having a medical condition prior to applying for health care benefits. For example, common pre-existing conditions include hypertension (high blood pressure), obesity, and asthma. There are some pre-existing conditions that happen at birth such as having cerebral palsy or a mental disability. Other pre-existing conditions include having had a heart attack, a bout with cancer or diabetes.
Health plans carefully consider potential new member’s pre-existing conditions before accepting a person into the health plan OR before offering an employer group a health plan for its employees. The idea of pre-existing conditions means there is risk to the health plan. Those with pre-existing conditions may cost the health plan more than those people who have no conditions. Thus, the health plan seeks to minimize its own risk.
There has been much written in the media about how having pre-existing conditions precludes some people from ever having health plan coverage OR prevents people from changing jobs. While a current employer group must cover an employer with health plan coverage once the employee has been part of the health plan, a future employer group has not been obligated to do the same thing. Also, there are cases where health plans cancelled health plan coverage for covered people due to the finding of a pre-existing condition that may not have been reported. Egregious cases bubble to the top demonstrating how unfair health plan determination can be when related to pre-existing conditions.
The Patient Protection and Affordable Care Act (PL- 111-148) was enacted in March of 2012. This is also the legislation that may be referred to as Obamacare. Part of the PPACA does regulate pre-existing condition clauses. The regulation clamps down on how health plans can or cannot use pre-existing conditions for determining health plan coverage OR in even accepting people into a health plan. The act also creates several steps on ways to provide those with pre-existing conditions credible health plan coverage. The plan is detailed an inclusive of most all cases that have occurred. Many with health care issues have welcomed these regulatory changes. Further, employers and employer health plans cannot deny new employee coverage. This has been watershed changes for many people who have health issues.
The issue of pre-existing conditions will likely continue to be a “hot button” topic in the upcoming legislative year. The continual policy revisions will likely continue to focus on the issue of fairness and access to credible health care coverage for those who are considered to have pre-existing conditions. It is likely that every family is touched with having an issue of pre-existing health conditions. Do pay attention to these types of discussions. The topic is important for health care managers and most US citizens.
Dr. Cheryl L. Anderson earned a BA from the College of St Scholastica, Duluth, MN in physical therapy; a MBA from the University of St Thomas, St Paul, MN; a doctorate in health services management with a concentration in health policy from Walden University; and is a board certified geriatric clinical specialist. Dr. Anderson has been a licensed physical therapist for 32+ years spending much of her career focused on issues of older adults, rural health, health promotion, and ethics. You can learn more about the Health Care Management programs at our schools by clicking here.