Nearly a third in TN have pre-existing conditions
Insurance could be declined if ACA repealed
Kim Elrod remembers well what it was like trying to buy an individual health insurance policy before the Affordable Care Act.
Then a small-business owner, Elrod had been eligible for Tennessee’s Medicaid program, TennCare, because her pre-existing medical conditions made her “uninsurable.”
When Elrod became one of more than 100,000 Tennesseans dropped from TennCare’s rolls in 2005, she was willing to pay for private insurance — but she couldn’t find a policy she could afford. The premiums for the best-priced plan she qualified for at the time were still out of her budget.
These days, Elrod, who works for a Knoxville nonprofit, has employersponsored health insurance, but she’s conscious of what a repeal of the ACA might mean for people who could be declined for insurance based on their health history.
“Everything can be linked to something else — if you have Type 2 diabetes, or high blood pressure, even if it’s not included in your ‘pre-existing condition,’ insurers could link it to a past health problem and refuse to cover it,” Elrod said. “I have faith in the God who’s always provided for me . ... Were I a person who had no faith, I’d be terrified.”
Tennessee third highest in ‘declinable pre-existing conditions’
Nearly one-third of non-elderly adult Tennesseans — 32 percent — have at least one medical condition that would have allowed insurers to decline them coverage prior to the ACA, a study released last month by the nonprofit, nonpartisan Kaiser Family Foundation found.
That’s about 1.27 million people. Nationally, it’s about 52.2 million people. Though Tennessee, not surprisingly, is among the states with the highest number of people with chronic health issues, in 11 states more than 30 percent of nonelderly adults have “declinable pre-existing conditions” — and in every state, it’s at least 22 percent.
West Virginia, at 36 percent, has the highest number, followed by Alabama and Kentucky, both 33 percent. Arkansas, at 32 percent, is tied with Tennessee for third place.
And in individual counties, the prevalence of people with pre-existing conditions can be even higher. In Kingsport, in Northeast Tennessee, for example, it’s 41 percent.
Not all of these people, of course, would be seeking individual insurance policies at a given time. Most people have group insurance through a job or spouse.
But many of those seeking individual policies would be between jobs, smallbusiness owners, or starting a new job — a particularly financially vulnerable time.
Before the ACA’s passage in 2014, individual insurance policies in Tennessee, as in most states, were medically underwritten: Insurers looked at your current health, health history and risk factors, then decided whether to offer you a policy, a process the insurance industry long said was necessary to keep insurers solvent.
And if you were offered a policy, in spite of pre-existing conditions, it could have certain conditions:
❚ significantly higher monthly premiums or overall deductibles, the amount you have to pay before coverage kicks in.
❚ riders excluding treatments for those pre-existing conditions, or even the body part or system they affected.
❚ limited benefits; for example, no prescription drug coverage.
The ACA guaranteed coverage in spite of pre-existing conditions, prohibited insurers from varying premiums based on people’s health, and required insurance plans to cover a set of “essential benefits” that included maternity, mental health and substance abuse care.
As a young woman, Elrod had already had a heart attack, triple bypass surgery, and cervical cancer that required a hysterectomy by the time she lost TennCare. In addition, she had other health issues, including diabetes, coronary artery disease, chronic obstructive pulmonary disorder, high blood pressure, high cholesterol, chronic Epstein-Barr virus, irritable bowel syndrome and osteoarthritis. Some she controlled with diet and exercise, others with prescription medications.
In 2005, her best option for individual insurance was a Blue Cross Blue Shield product, which she still couldn’t afford, she said. It would have cost:
❚ With a $1,500 deductible, 80 percent coinsurance and out-of-pocket maximum of $6,500: $434.62 minimum a month.
❚ With a $2,500 deductible, 80 percent coinsurance and out-of-pocket maximum of $7,500: $332.31 minimum a month.
❚ With a $3,500 deductible, 80 percent coinsurance and an out-of-pocket maximum of $8,500: $287.98 minimum a month.
Diagnoses, drugs, jobs ‘declinable’
Elrod’s health issues started in her 30s, but Nashville-area resident Megan Lane has dealt with “pre-existing conditions” her whole life.
“When I was a child, I was denied insurance due to Type 1 diabetes, diagnosed at 15 months of age,” Lane said. “My family was on one plan, and my coverage was through an entirely separate company and cost the same amount as my mother’s and father’s insurance combined.”
As an adult, “because of the diabetes, I was limited in jobs I could, or could not, do — employee insurance was a must,” Lane said.
Now married, she’s insured through her husband’s employer-sponsored policy and is able to pursue her dream job: event coordinator and dance teacher. It’s entirely contract work, so she doesn’t qualify for benefits.
“My husband and I actually eloped a few months prior to our planned wedding so that I could take this position and use his insurance,” Lane said.
Using medical underwriting guides from a dozen individual market insurers, Kaiser Family Foundation complied a list of common health issues considered “declinable conditions” prior to the ACA.
Among them: AIDS/HIV; alcohol or other drug abuse with recent treatment; Alzheimer’s/dementia; arthritis, fibromyalgia or other inflammatory joint disease; cancer within a period of time (usually 10 years); cerebral palsy; congestive heart failure; coronary artery/ heart disease, Crohn’s disease or ulcerative colitis; diabetes; epilepsy; hemophilia; hepatitis C; kidney disease; lupus; mental disorders; multiple sclerosis; muscular dystrophy; obesity; organ transplant; paraplegia; paralysis; Parkinson’s disease; pneumocystic pneumonia; pregnancy; sleep apnea; stroke; transsexualism; and upcoming surgery or hospitalization.
Some insurers even maintained lists of high-risk occupations or activities that would cause them to decline people applying for policies, the study found. It included active military personnel, firefighters, EMTs and law enforcement, as well air traffic controllers, blasters/explosives handlers, bodyguards, crop dusters, hazardous material handlers, iron workers, loggers, meat packers/ processors, miners, nuclear workers, offshore drillers, pilots, professional athletes, sawmill operators, scuba divers, security guards, steel metal workers, steeplejacks, taxicab drivers and window washers. Exclusionary activities included flying, hang gliding and competing in “strong man” contests.
In addition, many insurers had lists of medications they wouldn’t cover, including some used to treat arthritis, diabetes, cancer, hepatitis, HIV/AIDS, angina, anemia, narcolepsy and several central nervous system disorders and mental illnesses. The fertility drug Clomid and the blood thinners clopidogrel (Plavix), Coumadin (warfarin) and heparin also made the list.
‘Wouldn’t be functioning’
Nashville resident Anne Marie Sherman, 31, has a rare genetic disorder affecting her connective tissue, which requires frequent doctor visits and several medications.
When Sherman was diagnosed at 29, she sought an insurance plan through the ACA marketplace, but at the time, none was accepted by Vanderbilt University Medical Center, where she was getting care.
“They are the only hospital in the state with the specialists I need to see,” Sherman said.
She bought a policy with exclusions through Farm Bureau, “but after five months, I got a letter saying I was being dropped because of my Ehlers-Danlos syndrome and ‘the instability in the health insurance industry,’ “Sherman said. “I appealed it with Farm Bureau. They denied my appeal.”
Around that time, Vanderbilt began accepting the Cigna Connect plan through the ACA marketplace, and Sherman qualified for a subsidy that covers her monthly premium.
“So that’s what I, luckily, have now,” she said. “I use my insurance several times a month either for doctor’s visits or medications. All the medications I need are covered. Without the medications, I would be bed-bound.”
Before becoming ill, Sherman worked as a child and family therapist. Now she works part time in child care.
But “before I found the right combination of medications that help me, I couldn’t drive, exercise, work or socialize very much,” she said. “Now I am able to do all those things.”
She’s “extremely worried” that, without the protection offered by the ACA, she’d be unable to find a policy that would accept her and cover the care she needs.
“It’s pretty much always in the back of my mind,” Sherman said. “I know I wouldn’t be functioning without” insurance.