Pre-Existing Conditions and the Potential Cost of Repeal and Replace on the Medically Underserved

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Michael Castellarin, MD

In March of 2010, the Affordable Care Act (ACA) became the most significant change to the US healthcare system in almost half a century. This January, health care reform again entered the national conversation as discussions to repeal and replace the ACA ensue. One of the most influential provisions of the ACA was the pre-existing conditions clause which led to a ban on medical underwriting, thus providing health insurance coverage for a multitude of people previously ineligible unless covered by an employer.

As a family medicine intern training at an urban federally qualified health center (FQHC), I care for the medically underserved; a population defined by their complex health care needs and lack of financial resources which, prior to the ACA, left this group particularly vulnerable to medical underwriting. As health care policy shifts once again, the importance of pre-existing condition coverage must be realized and must be protected, particularly for those less fortunate.

Prior to the passage of the ACA, the practice of medical underwriting was commonplace in the individual health insurance market. Common ailments such as diabetes, heart disease, and obesity left patients uninsurable. Those insured through an employer avoided underwriting but oftentimes those in medically underserved populations were forced to shop for health insurance on the individual market because of unemployment or low wage employment without employer-sponsored insurance.

According to the Kaiser Foundation, more than 25% of adults under 65 years old have medical conditions that would have left them uninsurable under pre-ACA underwriting practices.1 Furthermore, the foundation estimates that 18% of individual market applications were denied prior to ACA passage while commenting that this is probably a significant underestimate of underwriting’s impact as it doesn’t account for people who didn’t apply knowing they would be rejected.[1]Data proves that the ACA had a major impact on the number of uninsured patients presenting to FQHC’s across the country. In Michigan, the percentage of patients presenting to FQHCs without insurance dropped by nearly half from 31% to 16%.[2]Along with insurance came improved access to specialty care and an overall increase in FQHC patient volume.

As lawmakers work to find an alternative to the ACA, a number of alternative proposals for dealing with pre-existing conditions have been introduced, most notably the idea of “high risk pools”, in which sick individuals are placed into a separate insurance market and the cost of coverage is subsidized by the state. This system theoretically drives down prices for healthier people as insurance companies spend less on the chronically ill. Problems abound with high risk pool coverage, however. Statistics show that although high risk pools may decrease costs for the healthy, the most vulnerable are often still left uninsured due to high deductibles within the pools, caps on enrollment, and insufficient subsidization.[3] The Minnesota Comprehensive Health Association (MCHA) was one of the most successful high risk pool trials, yet for patients whose annual incomes placed them above the cutoff for Medicaid, about $24,000, high risk pools were the only option at a cost of $400 a month with a $2,000 deductible. Thus, anyone who met their deductible was spending 20% of their income on health care costs annually. Inability to sustain these costs still left much of the population with pre-existing conditions uninsured.

As a family physician with a much broader view of the health care system than others in our field, my peers and I have a responsibility to be knowledgeable and active advocates for intelligent health care reform.

The patients that we see not only deserve quality care, but their conditions and lack of resources put them in a position to be a significant drain on healthcare spending in the event that they once again find themselves without access to coverage. Losses in insurance could precipitate a spike in uncompensated care, most often received in emergency rooms, resulting in costs upwards of $88 billion dollars in medical expenses that would be covered federal and state dollars as opposed to insurance funding.[4] Though problems with the current system certainly exist, the underlying goal of providing a thoughtful and rational approach to insurance coverage to working class citizens must be preserved going forward.


1. Claxton G, Cox C, Damico A, Levitt L, Pollitz K. Pre-existing Conditions and Medical Underwriting in the Individual Insurance Market Prior to the ACA. (2016, December 12) Retrieved from

2. Udow-Phillips M,  Fangmeier J,  Lawton E.The Effects of the Affordable Care Act on Federally Qualified Health Centers in Michigan. (2016, August 31) Retrieved February, from

3. The pitfalls of replacing Obamacare. (2017, January 26). Retrieved February, from

4. Khazan, O. (2016, December 07). Repealing Obamacare Could Leave 59 Million Americans Uninsured. Retrieved February, from

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