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Comment by JMTQp8lwXL | Hacker News Reader

Pre ACA, pre-existing conditions could disqualify you from insurance. People with pre-existing conditions are the people that need health care coverage the most. We can't under-weigh the moral obligation we have to this previously marginalized group, when considering service may be slightly worse for people who have employer coverage.

How I see it: if you were in the pre-ACA pre-existing condition pool, your perspective would be vastly biased in a different direction. And nobody wants to end up in that pool. Nobody chooses that. That's why it's a net win overall.

People died because they don't have coverage (unfortunately, still happens, but substantially decreased by ACA). If things are slightly worse for people who already had access, It's such a small price to pay.

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My favorite one was pregnancy being a pre-existing condition so if your husband got fired (noone would ever fire a pregnant woman for no reason), you couldn't get insurance when you needed it the most.

Though (if both spouses were working & had access to employer sponsored insurance), wouldn't the husband being fired result in a qualifying change for the woman, allowing her to enroll on her employer's insurance plan, thus covering the pregnancy?

Or COBRA, unless you expect your pregnancy to last longer than 18 months.

COBRA these days ends up being way too expensive for most people to afford. Perhaps at one time it was a useful regulation. Now it is pretty unaffordable.

If it was useful, it was a very long time ago. I remember my parents being in between jobs in the late 90’s and early aughts and complaining that COBRA was extremely expensive. The only reason the law seems to exist anymore is for people who somehow have some expensive debilitating condition yet can still work (or are a worker covering a family member with such condition). And that’s a pretty small subset of all health insurance buyers.

Data seems to agree: in 2007 the usage of COBRA was 10%: http://www.cnn.com/2009/HEALTH/01/23/cobra.health.insurance/

I thought COBRA was exceedingly expensive in 2000. Now, the cheapest HMO Bronze plan is 300% more, adjusting for inflation.

Unless her employer's insurance plan excluded her based on the pre-existing condition of being pregnant. (which it certainly could have)

The point of trying to get on an employer's insurance plans were that people were not excluded for pre-existing conditions because the employer plans were less selective (and also correspondingly more expensive, though the employer contributions hid the additional expense from the employees).

Why would you expect people to want to open their own wallet to pay for your pregnancy-related medical expenses in exchange for premiums that are much smaller than the expenses you already know you're going to incur?

"noone would ever fire a pregnant woman for no reason"

Companies do this all the time. My sister worked at a major oil company that laid off all the pregnant women and new moms out on maternity leave within her department. (To be fair, they also laid off about 1/3 of the rest of the company as well.) It's totally illegal, but if you've just been laid off and have a new baby on the way are you really going to have the money or energy to fight a lawsuit? And even if 10% of people affected did, it's cheaper for the company to settle for $500K or so than to pay the salaries of all the people they fired.

I do believe that was unmarked sarcasm, so hazardous in these times.

I don't like the entire concept of "pre-existing conditions". It goes against the entire concept of caring for sick people.

We are all people. We all get sick sometimes. Sicknesses can last a long time, or a short time. Sick people need help. Help the sick people. Pay what you can (a reasonable amount) into a common pool and take what you need (only as much as you need)

Or turn it around and make it equally burdensome to both insurer and patient. If you acquire a malady while insured by a particular company, all medical expenses that are tied to that diagnosis must be forevermore paid by that insurer, even after the policy lapses, is cancelled, or the patient switches insurers.

If that sounds unfair to an insurer, that's great--now they know how we feel about it.

Insurers want to deny pre-existing conditions because they don't want to add already-sick people to their risk pool. They wouldn't have to, if the previous insurer was still on the hook for that diagnosis. But they'd never agree to that, because it exposes them to some of the same insolvency risk due to medical bankruptcy that some patients have to face.

> Pay what you can

Surely "what you can" should be relative to both your income and your need. We'd need to supervise the system to make sure people aren't taking advantage or else the whole system goes broke.

> into a common pool

We could also invest the money in the pool to make some extra cash and reduce what people need to pay in, we'd have to have an organization do that too.

> (only as much as you need)

How can we know what people need? We'd have to charge a token amount for office visits and medication so that people aren't frivolous with their medical visits, while perhaps guaranteeing an out of pocket limit in case of extreme illness. We'd also need some kind of system to verify that people are only taking what they need.

I think you just invented health insurance.

They’re describing health insurance, except for the part where you pay what you can and get what you need and people are all in one pool.

We probably have different ideas of "paying what you can". How do you judge whether someone is only paying what they can, or they are taking advantage? Not a rhetorical question.

One way is like we do today -- highly-paid positions often come with high-quality insurance, which is (ime) fairly expensive and low-paid positions have less expensive insurance that is a bit worse (all this on average, I'm sure there are outliers).

We are in different pools today but I don't see how that's meaningfully different than everyone being in one pool if the individual pools are large enough and you can't discriminate the population of the pools.

There are cases where it’s hard to tell if someone is truly paying what they can, but there are also cases where it’s easy: when it costs more than they can pay. Health insurance trivially fails the “paying what you can” criterion for sufficiently poor people.

> I don't like the entire concept of "pre-existing conditions".

If you have an elective health insurance system where people choose whether or not and when to participate, it implies this restriction.

Say you have private health insurance companies but don't allow them to prohibit members based on pre-existing conditions. Everyone will simply not get health insurance to avoid paying the premiums until the day they need it. That would make health insurance companies completely unviable financially.

This is why Obamacare both eliminated the pre-existing condition restriction and mandated people get health coverage. You can't have one without the other or you get the free-rider problem.

This is another reason why healthcare should just be universal. It doesn't work at all like an actual efficient market product.

Would a wait limit, like with hurricane insurance, help to mitigate this problem? You can't wait until the NWS declares a Category 4 storm is barreling towards you to buy coverage. I mean you can, but the coverage doesn't kick in until 30 days later.

AFAIK, preexisting conditions weren't a disqualifier for any employer-provided health insurance (which is why group policies are so expensive).

That's a slightly maddening thing about many these comments. If you were getting your healthcare through an employer, you had a lot more security both on the pre-existing conditions end and on the keeping coverage end.

I remember several stories in the news before the ACA about employees being pressured to find private insurance or even getting fired because they were raising the group plan's costs. Are you sure it's so cut and dry that it's something you should be maddened about?

Is there any legal basis for that or is that something negotiated by employers with the plan provider?

I don't know the details but my understanding is that it is partly covered by tax law - if the employer kicks employees who get sick off the insurance, they (and all the other employees) lose some or all tax deductions for health care premiums. The employer can, however, still fire people to get around that.

Your employer could fire you, though, if you all of a sudden developed an expensive medical condition. HIPAA would say that's illegal to do, but it'd be incredibly difficult to prove that was the reason you were fired.

True but we could have had preexisting without all the other garbage included. Some of it sure but overall I have yet to see any compelling data to say the tradeoff was efficient.

  pre-existing conditions could disqualify you from insurance

Only if you chose no insurance before diagnosis.

Under Obamacare, people can go with no coverage at all and, once diagnosed, then get care paid for without penalty. It's like letting people drive without insurance, then making insurance companies write retroactive policies for them after an at-fault collision.

Was the ACA the best to address the problem of pre-existing conditions?

https://www.theatlantic.com/business/archive/2011/06/why-has...

"There were supposed to be millions of people who were uninsurable because of pre-existing conditions. We heard lengthy testimony about their terrible plight. I don't think it's too strong to say that this fear--that you could get sick and no one would insure you, that's right, you, Mr. & Mrs. Middle-Class Voter--was one of the main reasons offered for the health care overhaul. It was estimated by Medicare's Chief Actuary that around 400,000 would sign up (the CBO estimated 200,000, but only because they assumed that HHS would use its authority to limit enrollment in order to stay within the $5 billion budgeted for the program). So where are all the uninsurable people?"

So if this is accurate, that is the size of risk pool isn't that large. Wouldn't be better to create a special program for people who fall into this category?

> Wouldn't be better to create a special program for people who fall into this category?

Why? The only difference between "people who have already been diagnosed with cancer" and "people who are going to be diagnosed with cancer" is that you know who the first group is. The second group is hidden among the "healthy" people.

But both groups will need the same treatment.

You didn't understand what I wrote. I am talking about the group of people that were uninsurable because of preexisting conditions. This group of people was used as a reason for the ACA. However when a pilot program was run before the ACA went into effect, the size of said group appeared to vastly over-estimated.

So the reason for a special program would be to help the people that need it and not mess with the entire country insurance.

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