Are You a Pre-Existing Condition?

I've referenced this story in a previous post, about a woman who was denied health insurance [1] because (a) she was raped, (b) sought prophylactic HIV/AIDS treatment because it was unknown if her rapist wore a condom, and (c) sought therapy for the psychological problems resulting from being raped (in her case agoraphobia [2], which made her afraid to leave her home. Because of all the above, she became uninsurable.

The story itself is a jaw-dropper, especially when you consider that she's an insurance agent. She knows something about the health insurance business, and she couldn't find anyone who would sell her a policy. This interview with Anderson Cooper puts a face on the story

She actually worked as a health insurance agent, counseling other people on their insurance benefits, while unable to get coverage herself. For more, check out A Woman is Not a Pre-Existing Condition [3].

Like Tammy Wynette once sang, sometimes it's hard to be a woman.

Why would an insurance company deny a woman coverage because she's been raped and is doing the right thing for her health by seeking treatment for conditions resulting from the rape? It doesn't seem to make sense at first, that needing care and trying to get the care you need can cause you to lose access to that care.

It seems a bit paradoxical until you think about it. Then you realize that, as William Fisher pointed out, health insurers are not in the caring business [4].

Now, maybe I have a simplistic mind, but frankly I don't understand why health care and insurance companies keep appearing in the same sentences.

After all, these two things are not the same. Insurance companies are not in the health care business. They are in the risk business. They assess risk and then charge you a fee - it's called a premium - to protect you against that risk. Just like your car or your home insurance. If your car gets wrecked, the insurance company doesn't make it better; it gives you money so that you can make it better. Same with home insurance; if a storm tears your roof off, your insurance company will send a contractor to fix it. 

So it is with health insurance. Health insurance companies don't do a thing to make you well if you're sick. That's the work that's done by physicians, nurses, hospitals and clinics. And these two groups - health care professionals and health insurance companies - are far from buddies. In fact, they're pretty intense enemies.

The reason is that the health insurance companies, being in the risk business, do whatever they can to reduce their risk. So, they are more than likely to deny all or parts of the care your doctor is prescribing to make you better. Their loyalties are to their shareholders. Shareholders who've seen a run of great profits, based on ever-rising premiums, based in turn on generous government subsidies and an almost total lack of competition among all these companies.

So, from the insurance companies' perspective a woman is a pre-existing condition, and there's little she can do about it. One woman, while discussing the story above, joking asked me "So, if I get a hysterectomy (assuming it's covered) would I no longer be a pre-existing condition?"

And the not-so-funny answer is, well, no. For starters, there's a certain level of risk in having a hysterectomy operation [5]. So it's unlikely an insurance company would cover it. Plus, a woman who's had a hysterectomy is still a woman, and   a woman who's had a hysterectomy can still be raped, and thus denied coverage. She can be denied coverage for being a victim of domestic violence [6], because eight states plus the District of Columbia allow it [7] to be treated as a pre-existing condition, and eight of of sixteen insurers use that right to deny insurance to victims of domestic violence [8]. [via Corrente [9].]

Granted, that would eliminate the "risk"of becoming pregnant, and thus eliminate the possibility of being denied insurance for being pregnant [10]. (Every pregnancy, after all, carried some degree of risk to the health of the mother or the fetus.) And that would eliminate the likelihood of being denied insurance for having a c-section [11], and the indignity of having your insurance company tell you to get sterilized if you want coverage [12].

The letter from the insurance company, available here in PDF [13], must be read to be believed. The two stunner paragraphs read:

The plan you applied for is an association group plan and is medically underwritten. As a general rule our underwriting guidelines require that we issue coverage with a rider excluding benefits for caesarian section delivery for three years. However, the Colorado Division of Insurance no longer allows us to place that rider for the individual. Unfortunately, we cannot collect sufficient premiums to offset the risk of paying for a repeat C-section deliver during the first three years of coverage.

In order to consider coverage without a rider, we require that certain requirements be met. One requirement is that some form of sterilization has occurred since the caesarean delivery. Also, women age 40 and over who had their last child two years or more prior to applying for coverage will not require a rider. Unfortunately, since you have not met either of these requirements, it would have been necessary to place the C-section rider.

It's unclear whether "some form of sterilization" includes the possibility of her husband having a vasectomy. (Though that also would eliminate the additional risks like having a child who is deemed uninsurable [14] for being a "breath holder." [15]) but the insurance company's letter does underscore Fisher's point that health insurance companies are not in the health care business.

They're in the risk business, and the lower you level of risk is in their eyes, the better you look as a customer because you're likely to pay your premiums and not need much more health care than an occasional check-up. It's kind of like insuring your car, if you're a low-risk customer who car isn't likely to need much more than the occasional tune-up.

And it seems that's where the insurance model falls apart. While talking about health care reform over dinner, my husband (who happens to be a doctor) made the same observation as Fisher: health insurers want you to use health insurance the same way you use home insurance and auto insurance.

My immediate response was, "That's impossible." Health insurance can't work the same way that home insurance or auto insurance work. I say this as someone who hadn't owned a car for more than ten years, and who lived without one for nearly seven or eight years (before I married someone who owned a car). Instead I relied on a mixture of "personali responsibility," "public options" and private resources — in other words, walking, relying on public transportation, or hopping in the occasional taxicab.

In other words, I "opted out" of car ownership. Likewise, I "opted out" of home ownership for many years, choosing to rent instead. (Thus, I did purchase renter's insurance, which is cheaper than home insurance.) I don't have to own a car, and I don't have to own a house.

But, I can't "opt out" of having Gastro Esophageal Reflux Disease, and which can come across as trivial ailment (as so many ailments do, initially) that's no more urgent than "indigestion." Untreated and undetected, however, it can cause esophageal cancer, in which case I couldn't "opt out" of cancer any more than my mom and my sister could "opt out" of breast cancer. In fact, I couldn't "opt out" of any other serious medical condition — like muscular distrophy [16], multiple sclerosis [17], tumors [18], a congenital heart condition [19], celiac disease [20], polycystic kidney disease [21] — or any number of maladies that can affect the human body, because I can't "opt out" of having a human body the way I can opt out of owning a car or a home that also requires insurance.

I can't opt out of being a human being any more than my female friend can opt out of being a woman, as well. No one can. And given the number of things that can and do go wrong with the human body [22], the longer we're own one — as with a car or a house — the greater the risk that something is going to go wrong with it. That's especially true as these human bodies of ours age or are exposed to the every day risks of living.  If it has faulty wiring or missing parts, just try trading it in for a newer model, or selling it and buying "new construction."

So when you come right down to it, as Ellen Goodman wrote, we all share a common pre-existing condition called "being human." [23]

We can say a woman is not a pre-existing condition, but that's the status quo. And the truth is that as long as we keep it, then answer to the question "Are you a pre-existing condition?" is pretty clear: Yes. We all are, eventually.