What Counts as a Pre-Existing Condition?

Here's everything you need to know about pre-existing conditions and high-risk pools under the American Health Care Act.

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On Thursday, May 4, the U.S. House of Representatives passed the Republican replacement for the Affordable Care Act (ACA) by a narrow margin — 217 to 213 votes, to be precise. Next, it will head to the Senate for consideration, debate, alterations, and, ultimately, another vote.

In the meantime, though, Americans are left trying make sense of the proposed plan. Called the American Health Care Act (AHCA), or Trumpcare, the proposed bill would repeal and replace many parts of the ACA, aka Obamacare. For example, it would remove many of the protections that the ACA put in place for people with so-called "pre-existing conditions" — and that's got a lot of people talking.

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What is a pre-existing condition?

To better understand what this proposed change means, we first need to define the term "pre-existing condition." Turns out it's pretty vague: According to the U.S. Department of Health and Human Services, a pre-existing condition is any health problem you had before the date that your new health insurance plan took effect. Under the ACA, insurance companies couldn't refuse you coverage or charge you more simply because you had one of these conditions — but if the proposed replacement bill passes as it's currently written, that will change.

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How will Trumpcare change coverage for people with pre-existing conditions?

If the current version of the AHCA is passed, insurance companies still won't be able to deny you health coverage just because you have a pre-existing condition. What they will be able to do, however, is put you in a "high-risk pool" and charge you more money for your insurance plan — and, in some cases, the price increase might be so great that you're unable to afford the insurance plan at all.

The AHCA would allow states to "opt out" of the pre-existing condition protections in Obamacare and create high-risk pools instead. High-risk pools are nothing new: Prior to Obamacare, 35 states and the federal government had high-risk pools, which grouped "uninsurable" people with pre-existing conditions together and allowed them to purchase insurance from a separate market, according to Kaiser Health News.

In theory, these plans were subsidized by fees to insurance companies and taxes to keep premiums low and support the sickest Americans. In reality, however, insurers were still allowed to raise prices, which made premiums significantly higher for those in high-risk pools than for those not in high-risk pools. The pools were also notoriously expensive and underfunded: In 2010 alone, the 35 state pools incurred about $2.4 billion in total costs to cover just 221,879 people — less 1 percent of the uninsured people in those states, according to The Commonwealth Fund.

These issues are likely to rear their ugly heads again if the AHCA is passed in its current form. In fact, premiums could cost as much as $25,700 per year for people in high-risk pools, according to the American Association of Retired Persons (AARP).

What will count as a pre-existing condition under Trumpcare?

Prior to the passing of Obamacare, there was a long list of pre-existing conditions for which insurance companies could deny coverage or charge greater premiums. These same health problems would likely put someone in a high-risk pool if the AHCA is passed. Here's a look at the most common conditions from that list, as reported by the Kaiser Family Foundation:

  • AIDS and HIV
  • Alcohol or drug abuse, with recent treatment
  • Alzheimer's and dementia
  • Anorexia
  • Arthritis
  • Bulimia
  • Cancer
  • Cerebral palsy
  • Congestive heart failure
  • Coronary artery and heart disease, bypass surgery
  • Crohn's disease
  • Diabetes
  • Epilepsy
  • Hemophilia
  • Hepatitis
  • Kidney disease, renal failure
  • Lupus
  • Mental disorders (including anxiety, bipolar disorder, depression, obsessive compulsive disorder, and schizophrenia)
  • Multiple sclerosis
  • Muscular dystrophy
  • Obesity
  • Organ transplant
  • Paraplegia
  • Paralysis
  • Parkinson's disease
  • Pending surgery or hospitalization
  • Pneumocystic pneumonia
  • Pregnancy or expectant parent (including fathers)
  • Sleep apnea
  • Stroke
  • Transsexualism

And that's just to name a few — there are many other health problems that could count as pre-existing conditions under the AHCA. Experts predict the following conditions might also result in higher insurance premiums, according to TIME:

  • Acid reflux
  • Acne
  • Asthma
  • C-section
  • Celiac disease
  • Heart burn
  • High cholesterol
  • Hysterectomy
  • Kidney stones
  • Knee surgery
  • Lyme disease
  • Migraines
  • Narcolepsy
  • Pacemaker
  • Postpartum depression
  • Seasonal affective disorder
  • Seizures
  • "Sexual deviation or disorder"
  • Ulcers

What does this mean for you?

If you have health insurance provided by your employer, you most likely wouldn't be affected by the change in pre-existing condition coverage — but you could be affected in other ways, notably by having to pay high out-of-pocket costs if you get really sick, according to The Wall Street Journal.

If you have or plan to obtain individual insurance coverage for any reason, however, it likely would affect you; the change in pre-existing condition coverage will affect as many as 130 million Americans, according to a report by the Center for American Progress.

Of course, Trumpcare hasn't been passed yet — it still needs to get through the Senate, where it will likely be met with resistance. (The parties are divided on the bill, and there are a handful of Republican senators who have also spoken out against Trumpcare in its current form.) Senators will debate and make adjustments to the bill until they finally decide to cast their votes.

Until then, we wait.

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