By Robert Book
How many times have we heard, over the last three and a half years, that one of the primary and most popular features of Obamacare is that no one could be denied coverage for a preexisting condition?
The Affordable Care Act does indeed specify, in Section 1201, that “a health insurance issuer offering group or individual health insurance coverage may not impose any preexisting condition exclusion with respect to such plan or coverage.” In other words, a health plan cannot deny enrollment, or the plan’s benefits, to someone based on that person’s preexisting condition.
However, that is not the same as saying that a plan has to enable a patient to continue the same course of treatment that they started before obtaining coverage in an exchange plan on January 1, 2014.
Key to understanding this distinction is that having “health coverage” is not the same as actually obtaining “health care.” The insurance plan has to take anyone who wants to enroll, regardless of their health status or health history – but they don’t have to provide the same treatments, the same doctors, or the same medications that a patient has been receiving.
For someone in the middle of a cancer treatment, or someone with a chronic condition, this can be extraordinarily distressing, and perhaps dangerous to their health.
Edie Littlefield Sundby writes in the Wall Street Journal that she is on the verge of losing her treatment program for stage-4 gallbladder cancer. Why? Her existing plan doesn’t meet the ACA standards, so it has to be canceled. Her treatment program involves doctors at both the Stanford and UC San Diego medical centers, and the M.D. Anderson Cancer Center in Texas – but there is no plan in the California exchange that includes both Stanford and UCSD centers in it network, much less M.D. Anderson. In fact, UCSD has joined only one provider network, and it’s a heretofore almost unknown type called an “Exclusive Provider Organization” (EPO). The “exclusive” means that in an EPO, coverage is provided exclusively within the network – there is no out-of-network coverage at, except what uninsured people get at the emergency room.
Despite the President’s repeated promises, there is no way Ms. Sundby can keep all of her current doctors, or her health plan, in the new system. Her preexisting condition doesn’t prevent her from enrolling in any of the new Obamacare exchange plans – but none of those plans actually cover the same treatment she was receiving for her preexisting condition.
Ms. Sundby’s predicament is probably not an isolated case. Abby Goodnough of the New York Times reports that many people are having extreme difficulty finding out whether the plans they are shopping on the exchanges will cover the current doctors or hospitals they go to, or the drugs they take.
The problem will probably turn out to be most severe in New York. New York has set up its own exchange, and all of its plans are EPOs. That means no out-of-network coverage – yet the exchange web site doesn’t provide a list of in-network providers, or a search tool to determine whether particular doctors or hospitals are included. In fact, of the 14 states (plus DC) that run their own exchanges, only four states even claim to have provider search tools. The federal exchange just links to the provider directories of the insurers selling plans on it.
Nancy Pelosi famously said that we had to pass the health care bill to find out what’s in it – now you have to sign up for a health plan before you find out what’s covered.
This is not just a “glitch” – it’s a real problem that will affect actual care for millions of Americans with preexisting conditions. Ms. Sundby has been fighting stage-4 gallbladder cancer for seven years, against horrible odds – the five-year survival rate is 2%. Now, she is fighting to avoid becoming the first Obamacare fatality. She is not likely to get much help from the Obama Administration; as Secretary Sebelius said concerning a different patient, “someone lives and someone dies,” and she seems to regard her job as to remain neutral when the choice is between life and death.