ACA, Health Reform, Pre-Existing Condition, Federalism, health insurance

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As of January 1, 2014, applicants for comprehensive health insurance do not face questions about their health history. The ACA prohibits health insurers from considering an individual’s health history in determining whether to sell that person a comprehensive health insurance policy, the policy’s price, or its coverage terms. Pre-existing condition (PEC) consideration is, in this crucial context, dead. Few will mourn its passing. This legislative milestone marks a significant step towards the goal of a healthier population. While celebrating this achievement, however, in this article I argue that we ought to recall the context of PEC consideration, its practical application, and its continuing potential to infect other aspects of health care coverage. The “struggle for the soul of health insurance” continues, decades after its description in Deborah Stone’s influential article. With the ACA’s reliance on private insurance, albeit under a much different regulatory framework, competitive pressures to favor the healthy will persist. Moreover, enforcement of the new regulatory framework will be hampered by the ACA’s complex and contentious federalism dance. Vigilance will be required to ensure that those made vulnerable by illness or injury are not further disadvantaged by other key aspects of insurance, such as coverage exclusions, benefit decisions, and provider networks. Access to health insurance is only the beginning.



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