The Vault

Is the Fact that I Am a Woman Considered a Pre-Existing Condition?

The male body has long been considered the “standard” for health care coverage. Having a woman’s body is seen as an expensive anomaly, and women pay dearly for being different.

When they buy their own health insurance in the individual market, women must lay out an extra $1 billion a year, simply because they are women. Some argue that this is fair: after all, a woman could become pregnant, and labor and delivery are costly.

But the truth is that, even when maternity benefits are excluded, one-third of all health plans charge women at least 30 percent more, according to a report released just last month by the National Women’s Law Center.

In 36 states, “92 percent of best-selling plans charge 40-year-old women more than 40-year-old men,” the Center reports, and “only 3 percent of these plans cover maternity services … One plan in South Dakota charges a woman $1252.80 more a year than a 40-year-old man for the same coverage.”

Today, less than half of American women can obtain affordable insurance through a job, which explains why millions buy their own insurance in the individual market. In that market, just 14 states ban gender rating:  California, Colorado, Maine, Massachusetts, Minnesota, Montana, New Hampshire, New Mexico, New Jersey, New York, North Dakota, Oregon, Vermont, and Washington.

Pricing based on gender also plagues the small group market, where insurers frequently jack up premiums if a small or mid-size business employs too many women. This means that many of these employers just can not afford to offer insurance. Only 17 states address the problem.

Insurers explain that women cost them more, even if policies don’t cover maternity, because “they are more likely to visit doctors, get regular check-ups, take prescription drugs, and have certain chronic illnesses.”

In other words, women are penalized for taking care of themselves, As for those “female chronic ailments,” men also are more vulnerable to certain diseases – including many caused by smoking (23 percent percent smoke vs. 17 percent of women).

But insurers ignore male vulnerabilities. As Soraya Chemaly points out on BlogHer: “In most markets if you are a non-smoking female you will pay more than a smoking male of the same age because you possess ovaries and not testes.”

And that is if you can get insurance.

All too often, a woman is closed out of the individual health insurance market because her medical history reveals a pre-existing condition.

For example, if a woman lives in North Carolina, Oklahoma, North Dakota, or Mississippi, and has been the victim of domestic violence, it is perfectly legal for a company to refuse to sell her a policy.

In 45 states, insurers can reject her because she has had a C-section – even if it was medically mandated.

Insurers see “Caesareans or beatings as pre-existing conditions that are likely to be predictors of higher expenses in the future,” the New York Times explains, pointing to Peggy Robertson, a 41-year-old Colorado mother who was denied insurance in 2007. A broker advised the Robertson’s to switch their insurance to Golden Rule (owned by United HealthCare), where they would get a better rate. But when they applied, the company spotted a C-section on Robertson’s record, and sent her a letter, explaining that if she wanted insurance she would have to be sterilized.

If a woman is raped she, too, risks being shunned. When Christina Turner was attacked by strangers, doctors advised that she take HIV medication “just in case.” Insurers then refused to cover her because the HIV drugs “raise too many health questions.” They told her they would reconsider her in three years if she could prove she did not have AIDS.

Turner went without insurance for three years. Other rape victims report being denied because they suffered from post-traumatic stress syndrome.

These are the most shocking cases. Other rules discriminate against millions of women for a long list of commonplace reasons:

  • If a woman has survived breast cancer, this is a pre-existing condition.
  • If she is pregnant when she applies, this also is considered a pre-existing condition, just like cancer. Most likely, she will be turned down.
  • If she is of child-bearing age and has children, this may well viewed as a pre-existing condition, leading to higher premiums.
  • On the other hand, if she is infertile, this too, can be labeled a pre-existing condition.

Not long ago, House Minority Speaker Nancy Pelosi summed up the hurdles: “If you’re a woman, it’s a pre-existing condition.”

When Vice President Joe Biden told President Barack Obama that health reform is a BFD, he wasn’t kidding. The Affordable Care Act (ACA) represents a major victory for women across the nation. Today, state law decides what insurers have to cover. Under reform, federal law will call for equal benefits in all states.

Begin with maternity benefits. In the 41 states where they are not mandated, a 30-year-old woman will find that only 6 percent of plans in the individual market now offer coverage. Guess how expensive those plans are. Under the ACA, maternity care will be considered an “essential benefit” that all insurers selling policies to individuals and small businesses must cover, without charging extra, beginning in 2014.

Some argue that women who want maternity benefits should pay more. “I don’t need maternity care,” Senator Jon Kyl (R-Ariz.) groused when the Senate Finance Committee debated “essential benefits.” Sen. Debbie Stabenow (D-Mich.) didn’t miss a beat: “I think your mom probably did.”

Enough said. One way or another, all of us benefit from prenatal care.

But maternity benefits represent just one way that reform addresses women’s health. The Affordable Care Act (ACA) also calls for:

Preventive services with no co-pays or deductibles: New Policies (issued or renewed on or after September 23, 2010) are required to cover services that many women need – mammograms, Pap smears, at least one well-woman care visit a year, contraceptive products and counseling, and screening and counseling for interpersonal and domestic violence. In 2018, these requirements will apply to all plans.

Essential benefits: In 2014, both all plans sold inside the new state-run health insurance exchanges and all new plans sold outside of the exchanges will be required to cover a specific set of essential health benefits. For women, these include maternity and newborn care; mental health services (including counseling for post-partum depression); preventative and wellness services; contraception; chronic disease management; and pediatric services for her children, including dental and vision care.

At the same time, the legislation bans:

Gender rating: In 2014, charging women more because they don’t have a Y chromosome will be outlawed both in individual and small employer markets. After 2017, if a state lets large employers into its exchange (and many will), the rule will apply to all large-employer coverage in the state.

Charging more for pre-existing conditions: Starting in 2014, insurers can not charge higher premiums, or deny coverage due to a person’s pre-existing conditions.

The bottom line: Under the Affordable Care Act, women’s bodies will no longer be viewed as exotic, but costly, deviations from the norm that just don’t fit into a health care system designed by, and for, men.

What happens if the Supreme Court overturns the individual mandate?

The Court might rule that if everyone is not forced to buy coverage, insurers shouldn’t be forced to cover everyone – especially if they are suffering from pre-existing conditions. (Without a mandate, the reasoning goes, many Americans will wait until they fall ill, and only then purchase coverage, secure in the knowledge that insurers will have to cover them, and can’t charge them more).

Even if you don’t like the mandate, you should consider what it would mean for women if insurers can charge patients suffering from a “pre-existing condition” whatever they like.

  • A recently divorced 62-year-old woman who is no longer covered by her husband’s insurance may find that she is closed out of the insurance market because she is a breast cancer survivor. Even if she can find an insurer who will take her, the penalty for having a pre-existing condition may well be more than she can afford.In insurance parlance, she will have to “go naked” until she is eligible for Medicare, keeping her fingers and toes crossed that her cancer does not recur or spread over the next three years. (If it does, she will have to spend down whatever savings she has, and perhaps sell her home, before she will be eligible for Medicaid.)
  • A young woman discovers that she is pregnant. She and her husband were not planning on having a child so soon. Suddenly, they find themselves facing thousands of dollars in medical bills. If the mother needs a C-section they may wind up owing as much as $24,400. (Five percent of U.S. hospitals actually charge more.) And that is if there are no serious complications.

Congress could vote to kill health reform

It is extremely unlikely that the Supreme Court will declare the entire Patient Protection and Affordable Care Act unconstitutional. Whatever the Court decides in June, women will retain protection against much of the sexual discrimination embedded in our current health care system – unless lawmakers set out to eviscerate the ACA.

As Soraya Chemaly points out on BlogHer: “The openly stated primary priority of the Republican Party is to overturn this law.” If that happens, “these discriminatory practices will continue and women will pay in complex ways.”

Even if President Obama is re-elected, Republicans and Democrats who oppose reform could constitute a majority in both houses, and might even have enough votes to overturn a veto on certain controversial issues – such as gender rating, or essential benefits. Many men believe that women should pay more. And they are not happy about covering maternity benefits, contraception, or post-partum depression.

Meanwhile, without the Affordable Care Act, we can not count on insurers to mend their misogynistic ways. Four years ago, the Women’s Law Center issued a national report titled “Still Nowhere to Turn: Insurance Companies Treat Women like a Pre-Existing Condition.”

Back then, the Center reached conclusions very similar to what it said in the report released last month. In 2008, “Some insurance executives “expressed surprise at the size and prevalence of the disparities,” Chemaly notes, but “apparently these executives weren’t surprised enough to do anything about it. . . By failing to rectify clearly discriminatory policies despite years of awareness, they continue to demonstrate their untrustworthiness.”

This is why, in the run-up to this fall’s election, voters should take a close look at their Senators’ and Representatives’ records when voting on major health legislation.

Not only women – but the many men who care deeply about their daughters, wives, mothers, and sisters – should think carefully about what repeal could mean for those they love.

Maggie Mahar is an author and financial journalist who has written extensively about the American health care system. Her book, Money-Driven Medicine: The Real Reason Health Care Costs So Much, was the inspiration for the documentary, Money Driven Medicine. She is a prolific blogger, writing most recently for TIME’s Moneyland. Previously she wrote and edited the Health Beat blog for the progressive think tank, The Century Foundation. Previous work for the Health Insurance Resource Center includes Will the Supreme Court strike down health reform? She also recently provided background on Congressional health care legislation for HealthReformVotes.org, a special project of the Health Insurance Resource Center. This post first appeared at healthinsurance.org

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Mee RuehleszDr. Rick LippinAmmonPat 1 Recent comment authors
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Mee Ruehle
Guest

Great Post!

sz
Guest
sz

Where *are* the women? At the risk of sounding shrill, vasectomies are covered. Birth control often is not. So we’re not even supposed to make the decision to avoid pregnancy ourselves? No wonder our premiums are higher.

Dr. Rick Lippin
Guest

“We have too many small hospitals in this country that are not used at maxiumu capacity. This is one reason why hospital care is more expensive in the U.S. than in Europe. (You can Google this, or I could, and provide the reference.).Some of these hospitals shoudl be closed– zeroing in on the hosptials that are providing sub-par care because they are just not that safe.Some could be turned into community heatlh centers or long-term health centers.Fewer hospital beds would mean somewhat longer waits for non-emergency elective surgeries but this would not hurt the health of the nation” COMPLETELY AGREE… Read more »

Maggie Mahar
Guest

Bob– Thank much for the source. I’ve put it in my file. On Medicare spending on hostpials, you write: “Medicare could solve this in 30 days if it had the guts to pay hospitals on what I call a ratcheted per diem basis.Medicare would come up with a number like $2000 a day that will fit into a national budget. The patient diagnosis would mean nothing Medicare would come up with a number like $2000 a day that will fit into a national budget. . DRG;s would be history. 6 days for a bypass would pay $12,000 and 6 days… Read more »

Barry Carol
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Barry Carol

Bob – Americans are nowhere near ready for anything that looks like overt rationing. Refusing to pay for services, tests, procedures and drugs that either don’t work or cost more than they’re worth is not rationing though. Fixed budgets for hospitals would probably result in rationing. With over 5,000 hospitals in the U.S. from large urban teaching hospitals to small rural community hospitals with very different cost structures, I don’t know how such a budgeting approach would work. Some areas are growing in population while others are stable or falling. It would be a nightmare in such a large, diverse… Read more »

Bob Hertz
Guest

To Maggie and Barry: I get my Medicare statistics from The Statistical Abstract of US — their health care section is about 25 pages and iit is terrific. The Abstract has some statistics on utilization that are fascinating and depressing. I don’t have my notes handy tonite so i am going from memory, but here are the basic numbers from 1990 to 2010 for Medicare Part A. The number of people on Medicare went from 34 million to 47 million during that period. The number of hospital admissions for seniors went from 12 million a year to 15 million a… Read more »

Barry Carol
Guest
Barry Carol

Bob – I agree with your estimate of 70 million Medicare beneficiaries by 2022. There are 47.6 million as of the end of 2011 according to statehealthfacts.org. There were roundly 40 million births in the U.S. between 1947 and 1957. Of the 2.4 million people who die in the U.S. each year, roughly 75% are 65 and older but, as of the end of 2011, 15% of Medicare beneficiaries were less than 65 years old – presumably those on social security disability for at least two years and dialysis patients. There will probably also be some upward creep in the… Read more »

DeterminedMD
Guest
DeterminedMD

“For one, doctors will be paid bonsues if they keep their patients out of the hospital.”, as said by Ms Mahar above. I am a physician, and that comment really bothers me, as it smacks of the past efforts of capitation by private insurers that did not help quality of care in any fashion. And the fact that she asks for Bob Hertz to provide his source for his comments about growth of Medicare patient population size, what is that about? Oh, if it is only 65 million, then that supports a possible counter proposal of her’s? This morning’s CNN… Read more »

Maggie Mahar
Guest

Bob- Thanks for your detailed reply. Can you give me your source for calculating how many will die before they turn 65, how many now on Medicare will die, etc. (Not questioning the numbers, but would be interested in reading the analysis and using the source in the future.) Just a few easons why the situation may not be as dire as it seems: 1) There is now a fair consensus (based on the Dartmouth research, http://www.dartymouthatlas.org) as well as other reserach that 1/3 of Medicare dollars are now squandered on unncessary treatments that provide no benefit; preventable errors, etc.… Read more »

Bob Hertz
Guest

Note to Barry and Maggie — You are correct that Medicare has seen a slowdown in the cost per enrollee. However, the number of enrollees is still going to grow from 45 million to about 70 million in the next decade. You just take the number of baby boomers who will turn 65, subtract those baby boomers who will die before they get to 65, subtract the current seniors who will die, and add back in the disabled who will qualify for Medicare…….. and you get to 70 million in 2022. 70 million times $13,000 per person, which would be… Read more »

Ammon
Guest
Ammon

I agree with your view. It’s the same (but in reverse) with auto insurance. Single males pay much more than single women.

Pat 1
Guest
Pat 1

Why not have a highly rationed national healthcare plan for all, paid thru taxes – then people who are not smart enough to continually share the high cost of healthcare risk, will be forced to pay regualarly and continuously for healthcare, and continuously have RATIONED healthcare, instead of blaming everyone else for becoming ill at the wrong time – namely when they CHOSE not to have health insurance. We have a serious problem in the US, that students aren’t taught financial basics like a checkbook, credit cards, wills, insurance – health, disability, auto, renters/home, long term care, life, etc?? We’ve… Read more »

DeterminedMD
Guest
DeterminedMD

Mandating everyone buy health care is just wrong. We have raised several generations, starting with the boomers, who overall as a group think accountability and resonsibility went way of the DoeDoe. As I have said over and over here at THCB, I have no interest paying for health care for smokers who refuse to quit, and will add people with poor lifestyle choices who become morbidly obese and will not make efforts to learn weight loss lifestyles. Let all the PPACA stallwarts call me Hitler, fake MD, and other clueless terms. People who make poor choices in wants and goals… Read more »

Maggie Mahar
Guest

Bob & Barry Barry is correct. I’ve wirtten about the slow-down. More to the point, Peter Orszag , the former Congressional Budget Driector has written about it. (just Google Orszag and Medicare spending.) Both the growth in health care spending in private sector and growth in Medicare spending has slowed. Medicare spending is now rising by roughly 2% a year. That’s more or less in tandem with GDP, which means that Medicare spending, ,as a % of GDP is not growing. And our Medicare bill will not double in 10 years. (The baby boomers will be joining Medicare ranks over… Read more »

Barry Carol
Guest
Barry Carol

Bob – Healthcare cost growth has finally started to slow in the last couple of years for both the commercial sector and the public programs. While the conventional wisdom attributes much of the reason for the slowing growth to the recession, we’ve seen slowing on the commercial side in areas not seriously impacted by the recession. People with Medicare don’t lose their health insurance either because of the recession yet cost growth remains low this fiscal year following less than 4% cost growth last year despite a growing number of beneficiaries. We’re just starting to get serious about attacking fraud… Read more »

bob hertz
Guest

Actually when I propose that Medicare taxes go up 1%, which brings in about $70 billion a year, I want that money to help subsidize a variety of non-PPACA programs for those under 65 (such as lending money to the uninsured at zero interest rates to help them pay for emergency operations, or helping the unemployed and self-employed pay for catastrophic health premiums.) My reason for using a Medicare tax is that it is very collectible. Most employers even small ones use a payroll service that would just make a click in their computer programs. I definitely do NOT believe… Read more »

Barry Carol
Guest
Barry Carol

Nate – I agree with your comment on CA. Even I may move out of NJ in a few years, in part because of high state and local taxes. At the federal level, I’ve argued for some time that the capital gains tax rate is too low relative to the top ordinary income tax rate – 15% for capital gains (and qualified dividends) vs. 35% for ordinary income. If we’re going to maintain the current tax structure, I think the capital gains rate should either go back to 28% where it was under the Reagan reforms or included in the… Read more »