High-Risk Pools, Pre-Existing Conditions and Other Lies: Why Tomorrow’s Health Care Vote Matters

dXvSVWord this evening is that the House Republican leadership has set a vote for tomorrow on the latest version of “Repeal and Replace.” Insiders and observers are saying that this is a sign Speaker Ryan and his whips have found the requisite number of “yeas” to get the bill out of the House and on to the Senate.

On the one hand, tomorrow’s vote doesn’t really matter. Whatever Frankenbill they cobbled together won’t last a day in the Senate before it gets shredded. And, whatever the Senate sends back to the House will be a non-starter for the lower house. So tomorrow is a little meaningless skirmish in a larger war. It will give the Umber Jackhole residing at 1600 Pennsylvania an empty victory he will claim in Tweet and incoherent interview alike but nothing much else.

On the other hand, the hand I care about this evening, tomorrow’s vote matters a lot. The Republican legislation – to the extent anyone knows what’s actually in it – substantially weakens the provisions of the Affordable Care Act. The authors of the bill know this. The administration knows this. Donald Trump doesn’t care what it does as long as it passes.

And yet all of these people are saying just the opposite and are thus perpetrating a fraud on the American people and on that basis, tomorrow’s vote matters very much. It is a test of whether our system still works, an opportunity to say, “Hell no” to this level of mendacity and grifter behavior.

If you’re already convinced on this point, you can skip the rest of this post and simply stop here with this call to action: Please call, email or visit your Congressperson tomorrow. Do it more than once. The main phone number is (202) 224-3121. You can find a list of Congressional offices (most with links to their direct phone numbers and emails) here. Don’t know how your Representative is? Look it up here.  Tweet at them, post on their Facebook pages. Share this with your friends and ask them to do the same. Ask your Representative to reject this legislation.

If, however, you’re unconvinced that tomorrow’s vote is worth your time or if some of your friends need more than just an ask from some random person on their Facebook feed, the rest of this post is for you and them.

At the core of the bill being voted on tomorrow is a set of changes that will allow insurers to return to many of their pre-ACA behaviors including greater price discrimination by age, the promotion of substandard plans, as well as cuts to Medicaid and – as has been much discussed – will create a pathway for the elimination of coverage for pre-existing conditions.

As I understand the proposed legislation, if a state asks the federal government for a waiver, insurers in that state can refuse to cover pre-existing conditions if 1) the insured person lets his or her coverage lapse and 2) the state sets up a “high-risk” pool or reinsurance program as a safety net. This is pretty much the way things worked in the pre-ACA days when – according to the New York Times – 35 states had such mechanisms.

So…let’s contemplate for a second how many Republican governors there are – 33. How many state legislatures are controlled by the GOP – 32. How many of those politicians have pledged their undying, unyielding hatred of Obamacare. Suddenly, that hurdle doesn’t seem so high.

The process for granting a waiver? Under the current Trump administration, I’m guessing that will be something that can be completed on a postcard and approved with a “looks good to me” review.

I’ll leave it to you to contemplate all the ways you can lose coverage in today’s world of economic dislocation. Suffice it to say shit happens.

“But wait! Wait,” the apologists will claim. Even if you’re right, those people will still have access to care. Through the high-risk pools.

Yeah, let’s talk about that idea.

Historically, as the Times article notes, those pools have been wildly underfunded, charged participants much, much higher premiums than the prevailing market, were capped in terms of how many people they would accept and how much they would pay out either in a year or a lifetime. As the Times noted, California had an annual cap of $75,000 per person and across all the plans – in all 35 states – a grand total of 230,000 people were able to get coverage.

230,000 people out of 321,000,000. Less than 1/10 of 1 percent of the population.

Needless to say the number of people with pre-existing conditions is substantially bigger than 1/10th of 1 percent. How much bigger? Try 270 times bigger. And, depending on where you live, a lot bigger.

That’s not hyperbole. That’s actual verified data, the stuff we used to call “facts” in the old days. Based on an analysis by the Kaiser Family Foundation, 27 percent of the people under 65 have a pre-existing condition. Add it all up, according to Kaiser, and you come up with more than 52,000,000 people who might find themselves with no coverage, unaffordable coverage or substandard coverage.

And, of course, as you get older, the prevalence of pre-existing conditions increases. The graphic from AARP below illustrates, the percentage of people in the 50-64 age bracket with a pre-existing condition ranges from 32 percent on the low end to 52 percent on the high end.


You might not have a pre-existing condition, but if you live in a family of four chances are someone in your family does. If your block has 12 families on it, three of them might be uninsurable under a loosened standard of coverage and could be bankrupted by the cost of care. As Jimmy Kimmel tearfully noted, even newborns come with pre-existing conditions and a family without insurance – or an insurance plan with a lifetime or annual cap – can find itself have to choose between caring for their newborn or sending him to college, owning a home or a retirement.

In case you’re interested in exactly what constitutes a pre-existing condition, you might be surprised to learn that you could pretty easily fall in that category. Pre-ACA, the list of conditions considered pre-existing included:


  • Alcohol and drug abuse
  • Alzheimer’s/dementia
  • Arthritis (rheumatoid), fibromyalgia, other inflammatory joint disease
  • Cancer
  • Cerebral palsy
  • Chronic obstructive pulmonary disease (COPD)/emphysema
  • Congestive heart failure
  • Coronary artery/heart disease, bypass surgery
  • Crohn’s disease/ ulcerative colitis
  • Diabetes mellitus
  • Epilepsy
  • Hemophilia
  • Hepatitis
  • Kidney disease, renal failure
  • Lupus
  • Mental disorders (severe, e.g. bipolar, eating disorder)
  • Multiple sclerosis
  • Muscular dystrophy
  • Obesity
  • Organ transplant
  • Paralysis
  • Paraplegia
  • Parkinson’s disease
  • Pending surgery or hospitalization
  • Pneumocystic pneumonia
  • Pregnancy or expectant parent
  • Sleep apnea
  • Stroke
  • Transsexualism

Pre-existing conditions could also injuries, previous surgical procedures and more.

I’m not alone in opposing this, of course, and neither is it a liberal thing. The famously conservative American Medical Association? Against it. Also the American Psychiatric Association, the American College of Physicians, the American Academy of Pediatrics, the American Academy of Family Physicians, the American Osteopathic Association and the American Congress of Obstetricians and Gynecologists. So too is the American Cancer Society, the American Diabetes Association, the American Heart Association, the American Lung Association, the Cystic Fibrosis Foundation, JDRF, March of Dimes, the National Organization for Rare Disorders, the National MS Society and others. The American Hospital Association? A no vote. Ditto for the Children’s Hospital Association and AARP. For too many reasons to enumerate, these organizations know the scam that’s being pulled and are screaming about it:

“None of the legislative tweaks under consideration changes the serious harm to patients and the health care delivery system if AHCA passes. Proposed changes to the bill tinker at the edges without remedying the fundamental failing of the bill – that millions of Americans will lose their health insurance as a direct result of this proposal.

“High-risk pools are not a new idea. Prior to the enactment of the Affordable Care Act, 35 states operated high-risk pools, and they were not a panacea for Americans with pre-existing medical conditions. The history of high-risk pools demonstrates that Americans with pre-existing conditions will be stuck in second-class health care coverage – if they are able to obtain coverage at all.

“Not only would the AHCA eliminate health insurance coverage for millions of Americans, the legislation would, in many cases, eliminate the ban against charging those with underlying medical conditions vastly more for their coverage.”

– American Medical Association President Andrew W. Gurman, M.D

Again, the authors of this bill also know all this. They know that they’re opening an easy pathway to exclusion of pre-existing conditions. They know the money they’ve set aside to support high-risk pools is inadequate for its intended purpose. They know the extra $8 billion they dramatically added to the bill today does nothing to change these calculations.

And yet they look us in the eye and tell us exactly the opposite. We cannot, should not, let this go unnoticed and unopposed. To the contrary, I hope that every Member of Congress goes to vote tomorrow with the credo of Anonymous echoing in his or her mind: We are legion. We do not forgive. We do not forget. Expect us.

That’s why tomorrow’s vote is important. Spread the word.

  • Austin




The Plantation Business

As always, words and images reveal values. The political fight over regulation of business, and the culture-war battle over health plans and contraception, reveal whether partisans are for the few or for the many.

In my view, a fringe of bad business actors, poorly regulated, pushed America off the economic precipice during George W’s term. Republicans believe the answer to our economic problems is less regulation. They trust the few. Government regulates on behalf of the many. Whose side are you on?

Now comes Marco Rubio, the Tea Party darling from my state of Florida, putting forward a bill that would allow any business owner to refuse to cover any health procedure he or she (mostly he, of course) morally objects to. This is clearly the few deciding for the many.

Some Democrats are eager to have this fight over birth control — imagining this front in the culture war was won long ago. They may be right. But as is often the case, the flames of the morality issues obscure the framework that holds up the conservative view — we’ll all be better off if the few can decide for the many.

That’s the plantation system. That’s paternalism. That’s elitism.

The new ruling class, of course, is the oligarchy. Wealthy business leaders. Let them decide and we’ll all be fine. We shouldn’t worry our pretty little heads about this stuff. How’d that work out when the oligarchy decided unrestrained speculation was good for all of us? In the 1920s, in the 2000s. Today’s New York Times shows that the financial industry violated the law in 84 percent of foreclosures examined in a California study. Leave business alone and business will improve the economy and all of our lives. That’s the philosophy. What we’ve seen in the past decade — and past two hundred years — says leave business alone and too many businesses will damage the environment and make the economy work best for the few, ignoring whether it helps or hurts the many.

(I’m not anti-business. Most of my clients are businesses. My dad was a VP of General Mills, an ethical company. But too many businesses ignore three-quarters of what corporations are chartered to do — serve the community and employees and stockholders and customers. Too many serve only the people — mostly white guys — who run the companies.)

In the America of myth, we supposedly let the people decide. In fact, America has always been run by an elite — those of higher wealth and education. It seems to me that Democrats generally believe the people should have a stronger voice in how the country is run, including providing for the common good. It seems to me Republicans generally believe — despite their rhetoric — that the few should have a greater say, and that will be good for us all. Either side, taken to the extreme, is dangerous.

“This election is about whose side you stand on,” Massachusetts Senate candidate Elizabeth Warren said clearly — as she makes every issue clear with straightforward living-room, not hearing-room, language. “Here’s an example of giving power to insurance companies and corporations to undercut basic health care coverage. I’m going to fight for families to keep that coverage,” Warren said.

Who do you trust? The many, or the few?

— Bruce Benidt

(Photo of Oak Alley Plantation, from angelsghosts.com)


The other day at “The Great Minnesota Get Together,” Al Franken showed the right stuff. He was able to hold a reasonable discussion with a group of tea-baggers who wanted to know if he was going to vote “the way people want” (read that, Sean Hannity) on health care.

The body language here is quite interesting to watch. After asking her original question, the woman in the lovely TEA shirt begins rocking herself, as if to comfort herself and all other Right Thinking People who daily feel threatened by the proposed horrors of ObamaCare. Her sweet mom appears to take a quick nap, but comes to when Medicare is mentioned. The men all stand around with their arms crossed. That’s just what Minnesota men do. It doesn’t matter if they’re standing in a field of wheat, chilling at a summer garden party or watching a neighbor paint his house, THAT’S how Minnesota men stand.

Take that, Norm:

The Death of American Rx-ceptionalism

Amoxicillin (Generic Term) Antibiotics Perscription“Why would we want to desroy the best health care system in the world?” Starting with the 1993 Hillarycare debate, this has been the opposition’s most consistent and effective key message.

And sixteen years later, opponents continue to cling to that security blanket. For instance, Alabama Senator Richard Shelby recently told Fox News that President Obama’s proposal is the “first step in destroying the best health care system the world has ever known.”

Damn straight. Do you “reform” the home team after they win the championship? Do you “reform” the armed forces after they win the war?

Obamacare opponents’ Rx-ceptionalism argument is powerful, as long as citizens buy the premise that we’re The Best.

But here’s the problem. Americans are no longer buying it. According to a Pew Research survey, only 15% of Americans felt America had the best health care system in the world.

Fifteeen percent. If Obamacare supporters are looking for a hopeful sign, this is it. Americans always want The Best, but they no longer believe they are getting The Best.

So, yes we can?

It’s not that simple. A majority (55%) still say America’s system is either above average (23%) or average (32%). While that’s hardly a ringing endorsement, Americans will choose an average-to-above average health care system quo over an unknown, incomprehensible system being badmouthed by their doctor. And that’s the current calculus.

Health reform still has a shot, but only because President Obama has better congressional numbers than President Clinton did. But if it does pass, it will pass despite the majority’s preference for the devil they know.

– Loveland