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There does not seem to be a lot of hard data on how many applicants were denied health coverage before the ACA. I was an insurance agent myself, and I advised many persons not to even try for coverage because I knew they would be denied.
The Kaiser Foundation (which is pretty reputable) did a study in 2016 titled ‘Pre-existing conditions and Medical Underwriting in the Insurance Market before the ACA’ (12/12/2016)
They looked at the actual underwriting guidelines of several insurers in the individual market.
There were a lot of declinable conditions (and even some declinable occupations, like firefighting, logging, mining, etc.) The declinable conditions were what you would expect — rheumatoid arthritis, Hep C, Congestive Heart Failure, diabetes, MS, Crohn’s, fibromyalgia, heart bypass.
Not all of the sufferers went uninsured. Some got onto a spouse’s plan, others took any job that offered insurance.
Providing health insurance to people who are already sick is a very large challenge. There are roughly four traditional solutions:
a. Ignore the problem…”too bad, so sad……..you should have bought insurance when you were healthy.” This is basically the libertarian approach.
b. High-risk pools. This sounds like a decent solution, but getting a legislature to raise taxes for these pools is very difficult.
c. Guaranteed issue health insurance…i.e. The Affordable Care Act. This raises premiums for everyone, creating huge resentments.
d. Expanding Medicare and/or Medicaid. I do not know why this is not explored in more detail. Probably because it too would require higher taxes.
There are really two options:
1. Raise premiums to cover the risk, and/or
2. Supplement or replace the premiums with tax dollars.
All four traditional solutions do some combination of the two.
a. Raises the premium as the pool ages and shrinks, with essentially no taxpayer subsidy.
b. Set a moderate premium, higher than solution (a) but lower than actuarial cost. Taxpayers subsidize any pool shortfall until allocated funds are exhausted, and then new applicants go onto a waiting list.
c. Set a high premium and use taxpayer funds to provide income-qualified premium credits based on some arbitrary formula, so that lower-income members don’t see the full cost.
d. Set an artificially low premium and augment the pool with tax dollars and with arbitrarily-determined surcharges for higher-income members.
I don’t really see much difference between c and d, other than how subsidies and surcharges are labeled. They are either explicit or baked into the premium. Both could be made better or worse depending on the fairness of the pricing scheme.