As a doctor, I have never diagnosed a patient with a “pre-existing condition.” When I took my medical licensing exams, I don’t recall a multiple-choice question asking me the most important risk factor for pre-existing conditions. Pre-existing conditions don’t show up on CT scans or biopsies. I’ve never heard of a British or Canadian citizen coming down with the affliction. Yet this strange illness is all we seem to hear about in contemporary political discourse.
Pre-existing conditions have no natural correlate. They were an actuarial invention that addressed the needs of insurance companies: pricing individual premiums, cream-skimming the healthiest, lowest-risk patients, and finding clever ways to avoid paying for care. The Affordable Care Act, which I am politically required to tell you is far from perfect, essentially cured this condition. The ACA requires insurers, with few exceptions, to sell their insurance plans to all those who wish to purchase them, regardless of their state of health. Further, the ACA requires community rating, so insurers can’t charge the sick unaffordable prices. To balance out these increased costs on insurers, the ACA instituted an “individual mandate” and coverage requirements for businesses in the hopes that healthier people will purchase insurance and dilute the risk pool.
So in 2017, the pre-existing condition has been eradicated. Its elimination may rival that of smallpox for impact on morbidity and mortality in the United States. When President Trump or the GOP promise to cover all those poor souls who suffer from this disease, we must remember that politicians aren’t promising to cover the sick, but to commit an act of political bioterrorism by re-introducing an eradicated condition. Once we recognize that there is no human reservoir for the pre-existing condition, the only vector that remains is the political invertebrate, who finds the complexity of ensuring health insurance for the sick too onerous a task.
People don’t have pre-existing conditions. People have illnesses. As a country, we have to decide if allowing sick people to have affordable health insurance is important to us.