GOP Health Bill Leaves Many 'Pre-Existing Condition' Protections Up To States

May 8, 2017
Originally published on May 10, 2017 1:22 pm

Ryan Lennon Fines seems like a typical 2-year-old. He and his parents, Scott Fines and Brianna Lennon, flip through a picture book of emergency vehicles. Ryan is looking for the motorcycle, but a photo of an airplane catches his dad's eye.

"That's an air ambulance," Fines tells him. "You've been on one of those."

When Ryan was born in 2014, his mouth wasn't connected to his stomach. It's a condition known as esophageal atresia. After three months in a hospital in St. Louis, the family flew to Boston, where Ryan had surgery.

The surgery worked. Ryan is active and can eat normally — he had two big pieces of fruit leather and some crackers in the 45 minutes I was there. But all that time in the hospital was expensive. In the first six months of his life, Ryan's insurance plan was billed $750,000. The family had to pay only $5,000 of that — Ryan's maximum out-of-pocket expenses, under his insurance plan, for 2014 and 2015.

"We were lucky we had a really good, employer-provided [health insurance] plan," Lennon says.

Now, the family is worried about Ryan's future. He'll still need between $20,000 and $30,000 of medical care every year. They have insurance through Fines' work, but the health care bill that Republicans passed in the House last week could affect Ryan's care.

All six Republicans from Missouri — including Rep. Vicky Hartzler, from the district where Scott, Brianna and Ryan live — voted for the bill, which unwinds many of the provisions and protections of the Affordable Care Act, known as Obamacare. In a video posted to Twitter, Hartzler says passing the bill was an important first step to replacing the ACA.

"It covers pre-existing conditions," she says, "still retains the ability for young people to stay on their parents' policies, and makes sure that there are no lifetime caps."

That's true, but the bill also gives states the authority to allow insurers a number of exemptions from the federal law. For example, while the GOP bill retains the ACA provision that people, like Ryan, who have pre-existing conditions cannot be denied coverage, there's a potential loophole. In a last-minute amendment proposed by Rep. Tom MacArthur, R-N.J., a state could seek permission to allow insurance companies to charge patients more (based on their health history) if their coverage lapses for more than 63 days.

That provision in the GOP bill would tremendously weaken the ACA protections, says Larry Levitt, senior vice president of the Kaiser Family Foundation.

"This would guarantee access to insurance for people with pre-existing conditions in theory, but not really in practice — because they could be charged astronomically high premiums," says Levitt.

Before the Affordable Care Act was enacted in 2010, he says, it was common for people with pre-existing conditions to be charged much higher premiums or to be denied coverage altogether. If a state decides to waive the federal law's protections, this could happen again.

The amendment would require that states seeking a waiver must also help people who have high health care costs. High-risk pools are the most commonly cited type of program to do this, but they were often underfunded and expensive for consumers and states.

Missouri Gov. Eric Greitens, a Republican, supported the GOP health plan in March. His office didn't respond to NPR's questions about whether he supports the current version of this bill or whether he'd want Missouri to seek permission to opt out of some of the provisions. Levitt says it would likely be conservative states, like Missouri and the 18 other states that did not expand Medicaid, that may try to opt out.

Those states, Levitt says, "made a decision to not go along with the Affordable Care Act, and I think that those states are facing a similar kind of decision here."

Fines and Lennon say they face tough decisions if this bill becomes law.

"We would have to either move to a state that didn't waive community protections or out of the country entirely if we could," Fines says. "I'm not going to risk my son's health on the political whims of Jefferson City."

But before any decisions are made in Missouri's state capital, the GOP bill is in the hands of the U.S. Senate, where it could change before becoming federal law.


This story is part of NPR's reporting partnership with KBIA, Side Effects Public Media and Kaiser Health News.

Copyright 2017 KBIA-FM. To see more, visit KBIA-FM.

ROBERT SIEGEL, HOST:

Right now under the Affordable Care Act, people with pre-existing conditions have a lot of protections. But the House bill passed last week leaves a lot of those provisions up to state politics. Bram Sable-Smith of member station KBIA in Missouri reports.

BRAM SABLE-SMITH, BYLINE: Ryan Lennon Fines seems like a typical 2-year-old.

RYAN LENNON FINES: What's that?

SCOTT FINES: What is that?

RYAN: Fire truck.

FINES: That's right.

SABLE-SMITH: He and his parents, Scott Fines and Brianna Lennon, flip through a picture book of emergency vehicles. They land on a photo of an airplane.

FINES: Hey, there's an air ambulance. You rode in that. You rode in one of those.

SABLE-SMITH: When Ryan was born in 2014, his mouth was not connected to his stomach. After three months in a hospital in St. Louis, the family flew to Boston where Ryan had surgery.

FINES: And we were there from the 17th until just before Memorial Day that year.

BRIANNA LENNON: We're coming up on his discharge anniversary.

FINES: That's right (unintelligible).

LENNON: It's May 12.

SABLE-SMITH: The surgery worked. Ryan's active. He can eat normally, and he eats a ton. But all that time in the hospital and the surgery were expensive.

FINES: Our insurance was billed about $750,000. And it was 2014, so the ACA was in place, and we didn't end up having to pay $750,000, which was very nice.

SABLE-SMITH: Now the family is worried about Ryan's future. He'll still need about $20,000 to $30,000 of medical care every year. And even though they have insurance through Scott's work, the bill that passed the House last week could really affect them.

All six Republicans from Missouri voted for the bill, including Representative Vicky Hartzler from the district where Scott, Brianna and Ryan live. In a video posted to Twitter, she said passing the bill was an important first step to replacing Obamacare.

(SOUNDBITE OF ARCHIVED RECORDING)

VICKY HARTZLER: It covers pre-existing conditions, still retains the ability for young people to stay on their parents' policies, and it makes sure that there are no lifetime caps.

SABLE-SMITH: But the bill gives states license to make a lot of changes. It does keep the provision that people like Ryan with pre-existing conditions cannot be denied coverage, but a last-minute amendment allows states to ask permission for insurers to charge more based on a patient's health history if their coverage ever lapses. This tremendously weakens the current protections, says Larry Levitt with the Kaiser Family Foundation.

LARRY LEVITT: This would guarantee access to insurance for people with pre-existing conditions in theory but not really in practice because they could be charged astronomically high premiums.

SABLE-SMITH: What's more, right now under Obamacare, there are limits to the amount someone would have to pay out of pocket any year, and there are no lifetime limits on benefits. Language in the bill may end up weakening those protections also.

Missouri's governor, Eric Greitens, supported the GOP health plan in March. His office didn't respond to questions about whether he'd want Missouri to opt out, but Larry Levitt says it's likely conservative states that might want to.

LEVITT: States that have not expanded Medicaid made a decision to not go along with the Affordable Care Act where they can, and you'd probably see those states facing a similar kind of decision here.

SABLE-SMITH: Scott, Brianna and Ryan face tough decisions if this bill becomes law.

Would you all consider moving?

FINES: I think we'd pretty much have to. We would have to either move to a state that didn't waive community protections or out of the country entirely. I'm not going to risk my son's health on the political whims of Jefferson City.

SABLE-SMITH: But before any decisions are made in Missouri's state capitol, the bill moves on to the U.S. Senate where it could change. For NPR News, I'm Bram Sable-Smith in Missouri.

SIEGEL: And that story is part of a reporting partnership of NPR, Side Effects Public Media and Kaiser Health News. Transcript provided by NPR, Copyright NPR.