Understanding the GOP Pre-Existing Condition “Continuous Coverage Exclusion” Provision

The Affordable Care Act eliminated preexisting conditions, but almost all GOP plans (including Tom Price’s plan) bring them back via a “Continuous Coverage Exclusion” for pre-existing conditions.

The Basics of the the “Continuous Coverage” provision for Preexisting Condition

This “Continuous Coverage” provision acts like it is covering pre-existing conditions, allowing Trump and the GOP to claim they are keeping protections for preexisting conditions, but actually just rolls things back to the way it used to be. Or at least that is the worst case.

So what do we mean by this? In a sentence or two, this “continuous coverage” provision proposed by past Republican plans replaces the individual mandate (and perhaps open enrollment) by allowing insurers to charge you a higher premium for X months if you have a break in coverage of longer than 60 days for any reason (less than 60 days and you have “special enrollment”, like it is now). It also, in its worst case version, sometimes includes limitations on what sort of care insurers would cover during that X month period.

Beyond that the exacts of this provision differ proposed-plan-by-proposed-plan (it is a proposed provision in many GOP plans like the “Better Way” plan and Price Plan, not a current law).

What ACA supporters would be looking for is a version that doesn’t exclude any services or sicknesses, has reasonable ratios of what can be charged, and reasonable time period.

For example, having to wait 18 months, having to pay 150% more, and having cancer and cancer treatments excluded is “very bad”, and having to wait 10 months, having to pay 125%, and having nothing excluded is “far better”.

If this provision alone replaces the mandate, then it is reasonable by many measures (as the current system can bar you from coverage for months for non-payment anyway, plus charge you a fee).

However, if this is written with loopholes that allow big exclusions or higher premiums it could be a disaster for people with lower incomes and preexisting conditions (as with the mandate you can buy in every year without penalty, and with this whenever you buy back in you’ll face a cost barrier).

TIP: To be clear, this is a provision found in repeal and replace plans suggested by the GOP, it is not a provision in ObamaCare (and not a provision Trump has committed to passing… so let’s make sure he doesn’t, or if he does in trade for the mandate, let’s make sure it is a reasonable version).

TIP: See our Alternatives to the GOP’s Pre-Existing Conditions “Fix” for our proposed solutions to the problems explained below. In short, a public option can help America avoid the sting of this exclusion by taking pressure of private insurers (this would also likely lower the cost of private market coverage).

TIP: The provision repeals the ACA’s protections and amends the already in place 42 U.S. Code § 300gg–41 – Guaranteed availability of individual health insurance coverage to certain individuals with prior group coverage to change the rules for pre-existing conditions.

What Does the “Continuous Coverage Exclusion” Do?

In simple terms, the “Continuous Coverage Exclusion” says, “if you don’t have continuous coverage, you don’t have guaranteed issue coverage!”

More specifically, the “Continuous Coverage Exclusion”:

  1. Makes it so insurers can charge you more and exclude coverage preexisting conditions for up to 18 months upon entering a contract (an 18 month preexisting conditions exclusion period”, see page 150 of Price’s law for his version; not every version is the same).
  2. … but only if you have a gap in coverage of more than 63 days before entering a new contract.
  3. Meanwhile, anyone who can’t get private coverage can buy into a high-cost sick-pool.

Here is the official language used in Price’s version of the bill (Starting on Page 150):

‘‘(2) LIMITATION ON PREEXISTING CONDITION EXCLUSION PERIOD.— 12 ‘‘(A) LIMITATION.—A health insurance issuer offering health insurance coverage in the individual market may not, with respect to an enrollee in such coverage, impose any pre-existing condition exclusion if such enrollee has at least 18 months of continuous creditable coverage (as defined in section 2701(c)(1)) immediately preceding the enrollment date.

and

‘‘(D) LOSS IF BREAK IN COVERAGE.—Sub-paragraphs (A) and (B) shall no longer apply to an individual after the end of the first 63-day period during all of which the individual was not covered under any creditable coverage.

Although one has to carefully read SEC. 221. REQUIREMENTS FOR INDIVIDUAL HEALTH INSURANCE and 42 USC 300gg-41 for the full scoop (the section does more than just this), and although this provision could be changed by the time a repeal and replace plan is enacted, as it is written here and in other GOP plans, it would greatly burden our poorest as anyone who can’t continue a plan for 63 days, in any year of their life, for any reason.

Thus, if you’ve ever, even for a short period, have not continued your health insurance for any reason (including getting sick or being out of work), or if you have ever been sick in the past and don’t want to continue the same coverage for your whole life, you are potentially getting a raw deal.

So, everyone except the very rich and healthy are potentially getting left uninsured here. It could certainly bring prices down (nothing is ever ALL bad, not even this).

What is the Difference Between the Mandate and Requiring Lifelong Continuous Coverage?

So, what is the difference between this and the mandate? NOTHING MORE THAN LANGUAGE and technicalities.

The “Continuous Coverage Exclusion” for preexisting conditions is essentially the new mandate, only more discriminatory.

If you don’t have continuous coverage you don’t have guaranteed issue coverage!

People are going to hate this provision and die figuring it out. Mark my words. ALL GOP plans include this, and this is likely what Trump means when he says “preexisting conditions will be covered.” This will be the provision that makes TrumpCare a dirty word. Which is fine for the wealthy, but not for the rest of us.

Learn more about ObamaCare’s Patient Protections and why they are essential.

FACT: 1 in 2 Americans technically have a preexisting condition.

FACT: Most people have a gap in coverage at some time. The only people who can avoid this are the very rich OCD who always remember to update their auto-pay and never run into insurance company errors.

CONSIDER: If you forget to pay your bill because you changed your charge card, you can be priced out of coverage for life and have to pay a higher fee for life under this plan. You could also have a lapse in coverage if your insurance application or payment was lost by the bureaucracy. A person could get sick, forget to pay their bill, get dropped, then have to wait 18 months to get treated and die waiting under this plan. The only alternative would be a high-risk pool (an insurance pool for those with pre-existing conditions) which would likely charge very high rates and be state run. Thus, sick people would be forced into high priced government-run healthcare if they wanted to survive, while the rich and healthy would get to continue their plans at lower rates. Please note that “lower rates” are essentially the only benefit of excluding sick people in this way.

A BETTER WAY? There are lots of better solutions, one solution includes a public option, another includes expanded basic original Medicare to all citizens. There are many moral ways to handle preexisting conditions, using the market to punish those with less economic liquidity is not one of them. The “Continuous Coverage Exclusion” should not be passed into law, a better way is needed, get the word out.