When Insurance Rules Really Matter - West Virginia Strong

When Insurance Rules Really Matter

Digging Deeper: By Dan Heyman

Charleston, WV – For the 40% of West Virginians with pre-existing conditions, the fight over whether insurance plans have to cover their medical problems is a big deal. But many also point to the way health insurance rules like those are freeing them – financially, professionally and personally.

The protection would “absolutely be life shattering” for someone building a middle class family to lose, according to Julie Warden. Warden is a Charleston communications professional married to an engineer. When she was 21, Warden was diagnosed with early onset arthritis, and two years ago they found out her four-year-old daughter has a similar, chronic joint disease.

“The financial costs alone and that would be really difficult on a family who didn't have coverage for that. When you're talking about something like arthritis, that causes debilitating pain – if I was unable to obtain the medication that controls it, it would absolutely cause issues with getting to work.”

The rule that policies have to cover pre-existing conditions is required by the Affordable Care Act. The ACA said all health plans have to cover ten essential benefits – things like preventive care, emergency services, and prescriptions, among others. The law also says insurance companies can not set annual or lifetime coverage limits, or deny (or charge more) to cover people who come into the plan with medical conditions like that of Warden or her daughter.

Healthcare activists estimate there are more than 30 million Americans – and 750,000 West Virginians – with pre-existing conditions, although those numbers can vary a lot depending on what conditions are included.

This state has on average an older, sicker, and poorer population. Economists say making sure folks with chronic illnesses like diabetes and high blood pressure have proper preventive care becomes an important workforce and tax base issue. It’s better to keep those people healthy and working, they say.

Warden says losing insurance rule “doesn't seem like it can be that life shattering, but when you have someone who's in severe pain who's unable to handle their daily tasks, it can absolutely affect their ability to go to work or take care of their kids or do you know normal everyday activities.”

Republicans opposed to the ACA – Obamacare – say the ACA is driving up premiums, and they point to the essential benefits and the insurance regulations as a big part of why that is happening. A federal court case led by the state of Texas threatens to end those insurance rules, asking the court to declare them unconstitutional. The federal Department of Justice and the state of West Virginia (specifically Attorney General Patrick Morrisey) have decided to join the suit, as have a number of red states. Many blue state AGs have joined the opposition to it.

Supporters of the ACA argue insurance premiums have been going up for years, and they say medical inflation and premium increases have actually slowed a lot since healthcare reform passed.

Most legal observers describe the Texas suit as a long shot, but they also see it as a central part of national Republican drive to undermine the ACA. Since healthcare reform passed, they point to the GOP’s continuous efforts to undo it – in Congress, federal agencies, and the courts. The insurance rules are a key part of how the ACA works, and if the lawsuit fails they say there will be other attempts to get rid of them.

Governor Jim Justice told West Virginia Strong in June that, “I would surely hope that we could find a way to be able to cover those people that have pre-existing conditions because that's a tough nut right there.”

He says if “somebody is really hurting, you always want to try to do everything we possibly can to help.”

West Virginia House of Delegates Health Committee Chair Joe Ellington – a Princeton Physician – also expressed sympathy those West Virginians worried about loosing their health insurance. But he said there are lawmakers who object to telling the insurance companies that they have to cover something – even if the patient brought the problem on themselves though a poor lifestyle choice such as smoking, overeating, drinking or substance abuse.

“It depends on what the preexisting conditions are a result of – bad behavior or just bad genetics. Some people can't help having a preexisting condition. But there are some that are self-generated. I don't know if it's fair for those to pay higher premiums that don't have have any problems.”

He says keeping everyone in one, big insurance pool does keep overall premiums affordable, but that also means that younger, healthier people help pay the cost for the older and sicker.

Last year, the Urban Institute found West Virginia has the third highest rate of past due medical bills of any state. But according to Consumer Reports, the number of personal bankruptcies in the U.S. is now half what it was before the ACA.

Critics of what CU reports say some of the fall in bankruptcies may be due to other things – a better economy, changes in the bankruptcy laws. But the authors argue medical debt is a key driver of bankruptcies, and that is declining.

Interestingly, the Urban Institute study found the portion of state citizens with medical debt lines up closely with the rate of uninsurance – the percent of the population that does not have health coverage. West Virginia’s rate of uninsurance has fallen dramatically since healthcare reform, but the study did not say if the state’s medical debt has also fallen.

But for people like Julie Schleier of Parkersburg, there is no question. She says without the law she would have to choose between bankruptcy or death.

She says in late 2013 a fall that broke her back kick-started a rare – and expensive – auto-immune disease. Schleier says it made it impossible to work. He husband is retired and on Medicare, but Schleier says she’s not quite old enough. “I’m counting the days,” as she puts it.

Schleier says the disease is incurable, but there are medicines that hold it at bay – for $10,000 a month.

“We have savings,” she says. “We have a house, we have things that we’ve worked really hard for, but we could have lost all of that."

Schleier says without the drugs, eventually her back would start crushing her ribs, which would start crushing her lungs. “So this is not a pretty picture.”

She says it would eventually kill her, “and I would be in excruciating pain all the time.”

Rev. Janice Hill of Parkersburg gained a moment of viral fame last year when a video of her talking about her daughter’s cancer with Senator Shelley Moore Capito spread around the internet. Hill was trying to convince Capito to vote against repealing the ACA because Hill credited the law with saving her daughter’s life.

Capito voted to repeal the ACA, but Hill still says it’s still helping keep her daughter alive.

“Because of the Affordable Care Act there's no annual maximum and there's no lifetime maximum benefit,” she says, noting that her daughter’s treatments are extremely expensive.

“My daughter is highly paid is a business professional with a great company. She has insurance now. But if the pre-existing conditions rule goes away and she got so sick she couldn’t work, she would definitely never be insurable.”

Health insurance, especially complex details like pre-existing conditions, is often the kind of thing people don’t think about. Until they get sick.

And as Warden puts it, “If we were unable to have coverage or obtain care, we'd be looking at a whole different ball game.”

For a more humorous take on the ongoing pre-existing conditions debate, check out Bil Lepp's "Pay Up & Die Cheaply" 

Dan Heyman has been covering West Virginia politics and policy for more than two decades. He likes dogs but has trouble keeping kudzu from swallowing everything he owns. For more of Dan's WV Strong content, click here.

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