If you didn’t have medical insurance through your job, would you be eligible to purchase it in the individual market?

Prior to the institution of the Affordable Care Act in 2010, it was a lot harder than you might think. However, since then, health insurers can no longer exclude those with pre-existing conditions from obtaining insurance.

But if the ACA is repealed, and insurance companies are no longer forced to follow this mandate, would you qualify for an individual policy?

Queens Hospital Emergency sign. 14 feb 2017
Insurance companies can’t disqualify you for having pre-existing conditions, but that might change. Cory Lum/Civil Beat

At first glance, this might not seem to affect a lot of people. Most of us are enrolled in health insurance at our job or have a family member who covers us if we are a dependent or spouse.

But there are several groups of people that rely on individual plans. Those who are no longer covered by their parents (currently over age 26, although that is also a part of the ACA and prone to repeal), those who are self-employed, those who are early retirees, those who are low wage workers who are not offered insurance at work and those who only work part-time, those who suffer a job loss, or those who are recently divorced.

Each of these groups contain potential seekers of individual health insurance policies.

If the ACA is repealed, the mandate to cover those with pre-existing conditions would go away as well, unless there are special provisions made to keep this rule intact. From a business perspective, it’s not profitable to cover those who are already sick.

The Kaiser Family Foundation found that up to 24 percent of Hawaii residents have conditions that could make them ineligible to purchase insurance.

As President Trump has declared that he is pro-business, it is questionable if he would fight to keep this provision in any new health care law.

How many Hawaii residents might that affect? Based solely on the medical exclusions, the Kaiser Family Foundation found that up to 24 percent of Hawaii residents have conditions that could make them ineligible to purchase insurance.

What types of conditions are included? The list is surprising. Based on pre-ACA research, major insurance companies were previously allowed to exclude potential policyholders who had a history of any of the following conditions: HIV, hepatitis C, diabetes, Alzheimer’s disease, cancer (within 10 years or other specified time duration), congestive heart failure, heart disease, chronic obstructive pulmonary disease, kidney disease, mental disorders, multiple sclerosis, Parkinson’s disease, morbid obesity, stroke, pending surgery or hospitalization, pregnancy and many others.

Any of these conditions could preclude someone from being eligible to purchase individual health insurance plans, and make them uninsurable. In some cases, insurance could be purchased, but no treatment for a pre-existing condition would be included.

Use of any of the following medications would also have been reason to deny coverage: insulin, tamoxifen, Humira, methotrexate, Plavix, warfarin, metformin, anti-psychotics, any HIV medication, erythropoietin and many others.

Certain occupations could also make someone ineligible for insurance, such as air traffic controllers, active military personnel, explosive handlers, bodyguards, firefighters, paramedics, ironworkers, police officers, meat-packers, offshore drillers, security guards, taxi drivers and window washers.

Presumably if employed, these people could get some type of insurance. But high-risk hobbies, including hang gliding, piloting small aircraft and scuba diving, could also make someone uninsurable.

Even those deemed eligible to buy individual policies could face higher premiums or coverage restrictions if they had acne, allergies, anxiety, asthma, high cholesterol, high blood pressure, kidney stones, migraine headaches, vertigo and other conditions.

As someone who has always had insurance through employment, I know I did not appreciate the considerably more restrictive environment of the individual policy market prior to the ACA. The very conditions for which someone might come to see their doctor could then make them ineligible to purchase insurance!

For all of the talk about repealing the ACA and how this has become a priority of the new administration, certain provisions should be retained, including not allowing discrimination against people with pre-existing conditions. Without this, many of my patients would not be able to get health insurance on the individual market, or have coverage for their health if they had hobbies that many of us enjoy here in the islands.

Given the potential for any of us to lose our jobs or become self -employed or retire early, having some type of protection that our medical conditions will not make us ineligible for insurance is a must.

I wouldn’t be eligible without it, would you?

About the Author