From The Trenches

(Healthcare Reform for the Real World)

#3: Pre-Existing Conditions

This is the third in a series examining the problems in our health care system from the real world where patients get sick and injured, and doctors and other health care providers work to heal them. In the series, we’ll identify the actual non-political problems, and offer sound, sensible solutions that we can enact to reduce risk and increase patient safety.

Pre-existing conditions are a nightmare of the health care insurance. The specter of pre-existing conditions affects not only the cost of healthcare, but also the very health of patients. Patients who are concerned that they will be diagnosed with something (pre-existing) that prevents them from getting health care insurance in the future may give inaccurate information to their doctors in attempts to avoid that diagnosis. Some avoid treatment altogether, allowing the disease / condition to progress further than necessary, before they’re finally forced to seek help.

In a significant way, we all have pre-existing conditions, in that we are born with genetic propensities to develop certain diseases.

Insurance companies tend to focus only on their direct costs, and some only consider what it costs them in the immediate moment, rather than looking towards the long-term overall cost. This is the reality: Illness and injury are costs best shouldered by everyone collectively. Prohibiting coverage based on pre-existing conditions means the public pays for a more severe version when the patient is forced to turn to public assistance to remedy the condition.

Let’s look at the relatively common disorder of Diabetes again. This isn’t just one disease, it’s actually at least two, and more accurately several. Type-2 patients who are diagnosed quickly and control their condition will incur an average cost of about $4 a month for an oral anti-diabetic. If the physician determines that a blood pressure reduction is in order, that may add another $4 per month. Though they aren’t necessary as frequently, once the condition is under control, test strips may add another $10 per month. In total, the regular recurring cost, then, is $18 per month for a Type-2 diabetic. That amount is well below deductible, so the patient will pay it. There may be a need for more frequent check-ups, and a few extra labs. Add a couple hundred dollars per year. Still within most plans’ deductibles. So why is this condition preventing people from obtaining health care coverage?

Some have quoted a study that suggests that Type-2 diabetics are as likely to have a heart attack as someone who has had a heart attack before. That, they suggest, justifies the exclusion of Type-2 diabetics from insurance coverage. If one follows the money, per se, one finds that the funding behind such startling studies is none other than the insurance companies seeking justification for the exclusion. In the real world, though, most diabetics become far more health conscious, more aware of what they’re putting into their bodies, etc., after diagnosis. They’ll often change their diet, add a safe exercise program to their lifestyle and wellness routine, etc. In such cases, the diagnosed diabetic is actually less of a risk than his non-diabetic peers. Insurance companies are all about statistics. Health Care Reform must address the financial realities, but it must also be about the well-being of patients. When the latter is addressed, the former is also appeased.

Someone who signs on for health insurance at 48 and develops diabetes at 50 has not cost the health insurance company anything one way or the other to date. If that same patient sees the light, per se, and wants to get coverage after being diagnosed with the condition, they still aren’t costing the insurance company anything to speak of. Such is the case with many other pre-existing conditions. Although some medications and treatments are more expensive than others, the fact remains that we will all pay the costs one way or another.

When a physician isn’t able to provide a patient with the best care possible because of fear of being black-listed by a pre-existing condition, the Patient Safety factor must be given highest priority. The health insurance companies have had many exemptions over the years. (See future articles for more on Anti-Trust Exemptions that they enjoy.) The ability to fall back on Pre-Existing Conditions to decline to insure people is a special exemption. (Normally, a company is not allowed to exercise prejudice against someone with a condition or disability in this country.) The insurance companies may save some money, but they do so at our expense. It seems clear that we would all be better off if people were treated for their conditions earlier.