Monday, August 31st, 2015


Insurers say your little bundle of joy is a pre-existing condition.

You've probably heard of "pre-existing conditions," which provide an escape clause for health insurance companies. If you have a pre-existing condition, an insurance company typically won't pay for treatment.

J. James Rohack, president of the American Medical Association, cited them when he was asked on Fox News Sunday on Aug. 16, 2009, whether the Democratic health plan would lead to rationing for older patients.

"Well, there's a myth that rationing doesn't occur right now," Rohack said. "In the United States, if a woman's pregnant and on the individual market (and) tries to get health insurance, that's called a pre-existing condition and it's not paid for. That's why this bill's important. It gets rid of some of the rationing that's occurring right now." The AMA endorsed the House version of health care reform legislation in July.

First, we should emphasize that he's only talking about the relatively small number of women who buy their coverage through what insurers call the individual market. About two-thirds of women have health insurance through their employer or their spouse's employer, and about 13 percent have public coverage such as Medicaid or military health care.

So the people affected by these limitations include the 19 percent now uninsured and the 6 percent who have coverage purchased on the individual market. These policies are sold directly to an individual by a private insurer, and the purchaser doesn't get the same consumer protections routinely given to those who have coverage through an employer. For example, people in employer-based health plans have benefited from requirements for maternity coverage that date back to the federal Pregnancy Discrimination Act of 1978. But individual plans are not included under that umbrella and are regulated state by state.



One category of individual policyholders has it slightly better ? those who leave an employer's plan that had given them uninterrupted coverage for the pre-existing condition in question. Under the Health Insurance Portability and Accountability Act of 1996, or HIPAA, people in this category can obtain a plan that covers their pre-existing condition once they have exhausted their old employer's coverage under the law known as COBRA. However, a state only has to provide a minimum of one "HIPAA plan" within its borders, rather than requiring that every insurer operating in the state offer one. Such plans may have unfavorable terms and high premiums.

So back to Rohack's claim. Health care reform legislation under consideration in Congress would, if enacted, improve the situation for pregnant women seeking health insurance by prohibiting restrictions based on pre-existing conditions. But for now, Rohack is correct that pregnancy is considered a pre-existing condition and prevents many women from getting coverage if they seek insurance on the individual market. We find his statement True.