Health Overhaul May Cure Pre-Existing Conditions

One part of the health care overhaul bill does seem to have broad support. It would change the individual insurance market — that's where people buy insurance on their own, rather than through an employer. Under the measure, insurance companies would not be allowed to deny you coverage based on pre-existing medical conditions.

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One part of the health care bill does seem to have broad support. It has to do with the individual insurance market - people who buy insurance on their own rather than through their employer. The bill would make a big change to that market. Insurance companies would not be allowed to deny you coverage based on preexisting health conditions. Right now there are people whose job is to do just that, and some of them spoke with Alex Blumberg and Chana Joffe-Walt from our Planet Money team.

CHANA JOFFE-WALT: They don't have horns, they don't hate humanity, they are nice, they have cookies in the break room. On Friday afternoon they bring their babies into the office here in Southern Connecticut.

ALEX BLUMBERG: The boss even makes sure that everyone has headsets so they don't hurt their neck while they're doing this all day long.

Ms. CINDY HURTSBERG(ph): Hi Mary, this is Cindy Hurtsberg with Health Plan One calling, how are you today?

BLUMBERG: Cindy works on behalf of health insurance companies, and she deals with the people who call in and want to buy individual policies.

JOFFE-WALT: Individuals, humans with problems, and Cindy's job is to figure out which kind of problem as quickly as possible. Mary - this caller's problem: fibromyalgia.

Ms. HURTSBERG: Unfortunately, Mary, based on the different carriers that we represent, the condition that you have is considered high-risk and it's an automatic denial for coverage. Okay. Sorry I wasn't able to assist you. Bye-bye.

BLUMBERG: In this office, they call them pre-exes, pre-existing conditions.

JOFFE-WALT: Yes, and in the next cube over it takes Andrew Seward(ph) 27 minutes into his call to find the pre-ex.

Mr. ANDREW SEWARD: When she said she had been in a car accident recently and she's on multiple pain medications.

BLUMBERG: Here are some other things that may disqualify you from every individual insurance plan: depression, migraines, AIDS.

CINDY: Obesity, asthma, pregnancy.

Mr. SEWARD: Pregnancy - that's a big one - heart disease, things like sleep apnea, you know, cancers, lupus.

CINDY: If someone's insulin diabetic; cholesterol, back problems.

JOFFE-WALT: If you didn't hear yourself mentioned anywhere in there, I promise it's only because we cut them off. Cindy says about half the people who call in get denied.

BLUMBERG: And a lot of the people who call in who are sick have to pay more. And this, of course, completely violates the average person's sense of justice. It seems wildly unfair that an insurance company would pick and choose who they want to cover and refuse to cover people who need insurance the most.

JOFFE-WALT: Okay. But to the insurance professionals in this room it feels exactly the opposite. It seems totally inappropriate that people call up already sick trying to get covered.

Bill Stapleton is the CEO, and he says people don't call him until...

Mr. BILL STAPLETON (CEO): Guess what? I've got a medical problem. I better go get insurance. Gee, I showed up and they wouldn't let me have insurance. So what's your problem? Well, I had an MRI. I think I've got a - you know, I think I've got a big problem. Of course you're not getting insurance. You can't show up and pay $100 and expect you're going to get a $10,000 procedure.

JOFFE-WALT: That's what insurance is for, though, right? The reason that you buy insurance is because when you get sick you need insurance to pay for it.

Mr. STAPLETON: Yeah, you feel bad about it. And the other side of the coin is, why'd they drop their health insurance? You take a risk if something bad happens and then you're not covered.

JOFFE-WALT: That, Bill says, is like asking for fire insurance when your house is on fire.

BLUMBERG: Health insurers are just doing what other insurers do all the time. You live in a place that floods a lot, a home insurer might not want to cover you. Car insurance, they charge you more if you're a bad driver.

JOFFE-WALT: Yes, but if this health care legislation passes, Congress is saying, insurers, you can't pick and choose who you want to cover. Essentially it's trying to make health insurance as unlike insurance as possible, to make insurers do the one thing that is most unnatural to them: stop worrying about risk.

BLUMBERG: We talked to Jonathan Gruber. He's a professor of economics at MIT. He's supportive of the health care bill. Still, he says, you can tell health insurers not to think about risk, you can ban pre-exes, publicly shame them.

Professor JONATHAN GRUBER (Economics, MIT): However, insurance companies may have subtle ways they can think of to figure out how to avoid the bad risks. I'm not smart enough to figure out what those are, but the insurance companies surely are and so there may still be a role for doing that.

JOFFE-WALT: Maybe they only advertise in very healthy neighborhoods.

BLUMBERG: Or they just happen to have a limited supply of cancer specialists.

JOFFE-WALT: Okay. But Alex, the legislation also wants us individuals to do something that is equally as unnatural. It says even if you're healthy...

BLUMBERG: I am.

JOFFE-WALT: ...even if you play basketball every weekend and eat well and never go to the doctor, you have to get covered.

BLUMBERG: What? That doesn't seem fair. I'm strong like a bull.

JOFFE-WALT: Sure you are. It doesn't matter. They agree to take you when you're old and sick, you have to pay them when you're young and bull.

BLUMBERG: I'm Alex Blumberg.

JOFFE-WALT: And I'm Chana Joffe-Walt, NPR News.

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