They’re Back!

They’re Back!


The Trump Administration and House Republicans are back for another try at repealing and replacing the Affordable Care Act. The salient new added-on features are state waivers of 1) community rating, and 2) essential health benefits. What does this all mean?

Community Rating

Prior to the Affordable Care Act, you could be turned down or charged higher premiums if your prospective insurer deemed you a poor health risk. In other words if you had a family or individual history of cancer or heart disease or diabetes or hypertension or a myriad of other medical conditions, insurers can and did deny you coverage, rescind your coverage and/or charge higher premiums. Some of you may remember filling out lengthy forms with your entire health history; some may remember being denied coverage based on a medical condition, and others may remember getting rescission notices after you sought medical treatment in which the insurer claimed you failed to mention on that application some medical fact. These individual underwriting practices by the health insurance industry were outlawed under the Affordable Care Act. The latest amendments from the right wing Freedom Caucus would allow states to restore these underwriting practices by charging far higher premiums to those with any medical conditions or health risk factors. States seeking such a federal waiver must establish and fund a high-risk pool. A high-risk pool would offer health insurance for all those whose premiums would now become too high to be affordable due to their medical conditions. In California for many years we had such a pool (MRMIP), which offered an insurance product with higher prices, limited health benefits and long waiting lists for the “medically uninsurable” to become eligible; it was not a good solution.

Ten essential health benefits

Prior to the Affordable Care Act, insurers sold policies that excluded mental illness, maternity care, prescription drugs, preventive care and other services. Some excluded hospitalization, while others only included hospital care. Frequently the fine print excluded care and treatments that even well informed consumers would have otherwise expected to be covered. The ACA specified that all policies had to cover the ten essential health benefits: basic hospital care, outpatient care, physician care, emergency care, maternity care, preventive care, mental health and substance abuse treatments, prescription drugs and habilitative and rehabilitative care (in other words how do you get back on your feet after a broken limb, heart attack or stroke, do you need a wheelchair or prosthesis if you have lost a leg or arm). There are no fine print exclusions and each state defines this care consistent with the most common and popular coverage in the state. The latest amendments from the Freedom Caucus would allow state waivers to permit insurers to offer far more limited benefits. Some of the proponents of these changes make arguments such as “why should men pay for maternity care” as if procreation and childbirth had nothing to do with males. Others want to exclude preventive services, such as birth control for religious reasons. In California prior to the ACA, there were very few limits or restrictions on how little coverage could be offered by a private insurance plan licensed by the California Department of Insurance, and many consumers were “surprised” when seeking medical treatments for cancer or coverage for the costs of child birth to find the needed services were not in their plans.


Take Action Now

A bad House bill that would take away ACA coverage for 24 million Americans is now getting much worse. It will now also empower states to take away important ACA protections for middle class consumers with individual coverage. If you or your friends, family members, colleagues and fellow church goers have a medical condition, “repeal and replace” is getting even worse for you. You may want to reiterate to your Congressperson your strong opposition to the bill and to these changes.


Prepared by: Lucien Wulsin

Dated: April 28, 2017


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