Thursday, October 22, 2009

Rape is a pre-existing condition

[Updated October 22, 2009, at 7:10pm: I fixed the Category. It should have been Med Stories.]

I hate stories like this. A woman (let’s call her Susan) believed she had been drugged and raped so she took anti-HIV meds to be on the safe side. When she applied for health insurance she was denied coverage because she had a pre-existing condition and told to try again in a few years if she was HIV-free.

What happened to Susan was terrible. She did the smart thing for herself medically by taking HIV meds and as a result she made herself uninsurable for three years. That certainly doesn’t seem fair.

However the reason I hate stories like this is that they rely solely on eliciting an emotional response and have no interest in the sort of long analysis that needs to be done to figure out what such stories are really telling us. In fact stories like this are intended specifically to keep us from doing any such analysis. The title of this post expresses this perfectly. It’s the title of the post at Movin’ Meat where I found this story; a Google search for that phrase plus “Susan’s” last name yields 800 hits. The title is certainly dramatic and enraging but is it accurate - or even defensible? No.

Let’s assume the insurance company is correct that it will be three years before Susan can know for sure whether she has contracted HIV. That is, latent HIV is a medically valid pre-existing condition. The insurance company has not made a medical error in its analysis of the situation. I do not know for certain that this is the case but Movin’ Meat didn’t argue otherwise so I’m taking it as a working assumption.

So Susan does have a pre-existing condition and the insurance company is treating it accordingly. It is not rape that is a pre-existing condition but latent HIV. Those who insist this is an example of rape being a pre-existing condition are saying that the insurance company was wrong to deny coverage to Susan since her exposure to HIV was a result of rape but would be perfectly justified in denying coverage to Susan if she had been exposed to HIV:

- as a result of one episode of consensual sex;

- through sharing a needle once;

- because she was a health care worker who treated a patient with HIV; or

- because she was a newborn whose mother was HIV positive.

So let’s talk about what these beliefs will look like when translated into health insurance legislation. We will forbid insurance companies to deny coverage to people whose pre-existing conditions were the result of rape. On the other hand, people whose pre-existing conditions were not the result of rape can be denied coverage.

Somehow I don’t think that anyone who is pushing the “rape is a pre-existing condition” line really wants that kind of legislation. Stories like this are not supposed to lead one to draw conclusions - or even to think them through. These stories are designed to make those who read them angry and sad and horrified at the villain of the piece - the insurance company - in order to achieve a goal - support for health insurance reform that is not in the interest of insurance companies. These stories do not lend themselves to careful consideration of exactly why we find them heart-wrenching which means they do not advance the cause of thinking through what we find objectionable in our current health care system. And they certainly don’t support attempts to consider what correcting the perceived horror will entail. They have no balance, no other side.

Susan’s story is not about rape. It is about - or should be about - how we want to handle pre-existing conditions. This in turn should lead us to a discussion of why insurance companies handle pre-existing conditions the way they do - because if they didn’t exclude people with pre-existing conditions they’d go out of business. From there we should consider whether we want to force insurance companies to accept people with pre-existing conditions. If we do then we have to realize that doing so will either drive health insurance premiums through the roof or put insurance companies out of business in short order. If we think putting health insurance companies out of business is a desirable outcome then we have to discuss how we’re going to handle health insurance instead. This almost certainly means some type of government intervention. The choices for government-run health insurance are the same as those for privately-run health insurance: everyone must buy in; buy-in is optional but pre-existing conditions get you excluded; or everyone who buys in is supporting those who wait to buy in until they’re sick.

On the other hand, if we want to avoid putting insurance companies out of business then we have to force everyone to buy health insurance from them. If we are not willing to do that then either we have to live with insurance companies denying coverage to people with pre-existing conditions or we have to live with sky-high premiums or we have to accept that government needs to provide health insurance in some way: either by taking it over completely or by providing health insurance for people with pre-existing conditions. If the former then we’re back to the same three choices: everyone must buy in; buy-in is optional but pre-existing conditions get you excluded; or everyone who buys in is supporting those who wait to buy in until they’re sick. If the latter then there is no choice: we all support those who wait to buy in until they’re sick.

Framing Susan’s story as “rape is a pre-existing condition” short-circuits that entire discussion. It makes it clear that the only decent responses to her story are to insist that no insurance company should be able to deny her coverage for her pre-existing condition and to accept that insurance companies are clearly rotten to the core. Only someone with ice in her veins would read Susan’s story and then point out that an insurance company needs to remain solvent and that providing coverage to someone who may have an extremely expensive pre-existing condition will make insurance more expensive for everyone else who buys it. And only a monster would point out that - whatever advantages government-run health insurance might have - it does not eliminate the relationship between required coverage and pre-existing conditions. A government-run plan that does not require everyone to enroll will face exactly the same issue: what to do about someone who is not enrolled in health insurance, who may have contracted HIV, and who now wants to sign up. Conversely if private insurance companies operated in a community where everyone was required to have insurance coverage this situation would never have arisen.

On paper the Baucus bill understands this relationship. It requires insurance companies to accept applicants with pre-existing conditions; this resolves situations like Susan’s. It balances this requirement with an individual mandate: everyone must buy health insurance. This gives insurance companies a big enough pool of healthy people to dilute the cost of covering those with pre-existing conditions. It also - and more importantly - means that there will no longer be people with pre-existing conditions who are not insured but want to become insured. So from that standpoint the Baucus bill looks reasonable.

There are reports, however, that the fines for the individual mandate are being decreased. If they are decreased to the point that they are no longer coercive or if they are not enforced we will have written exactly the kind of bill that Susan’s story could be expected to produce: one containing an emotional response to the problem of pre-existing conditions but lacking any understanding of the realities that cause that problem.


Paul Brinkley said...

The most obvious sin I'm seeing here is in the headline writing. Indeed, I could accuse you of same - we clearly both agree that "Rape is a pre-existing condition" draws the eyeballs like a mighty magnet - except that this is precisely the problem you're addressing.

It wouldn't be the first time we've seen a spectacularly emotional teaser to a piece of news. By far. We're used to it; network news has done this for decades by necessity - it draws eyeballs, which ultimately leads to more advertising revenue. It's interesting to me that weblogs would do it too, since I'm not quite sure the revenue model really works in similar enough fashion. I don't think bloggers commonly think about their revenue when they write headlines this way; they just do it, because they're accustomed to how much emotion a headline is "supposed" to evoke.

Beard said...

I think you glossed a bit quickly over Susan's situation, as far as I understand it from your essay. She believed she had been drugged and raped. She had no particular evidence that she had had sex with someone with HIV, except the increased likelihood that a rapist might have HIV. She did not have a pre-existing condition. She worried about the possibility, and took preventative treatment, just in case.

Arguably, if she had tested HIV-positive, then she would have a pre-existing condition, and since they are entitled to deny coverage for that reason, they would be justified in denying her coverage. But that is not the situation described here.

She believed she was drugged and raped, and she was worried so she took precautionary measures. She is being punished for being cautious, not necessarily for being raped, but it seems to me that the insurance company behavior looks almost as egregious.

Beard said...

Elaborating further, a bit.

What does it mean to have a "pre-existing condition"? Doesn't it mean, actually having the disease or other condition for which you are requesting them to pay?

Or does it mean, belonging to a higher-than-average portion of the risk pool for that particular condition? Since I am over 50, my risk of cancer and heart disease is higher than it was when I was 25. Does that mean I have those things as a pre-existing condition? Surely not.

How about if I smoke? Does that mean I have lung cancer as a pre-existing condition? Or choose to ride a motor-cycle? Do I have broken bones as a pre-existing condition? Again, surely not.

I don't know the details on this, but arguably, the actual condition resulting from HIV infection is AIDS, which is in fact a very serious illness requiring expensive treatment. (Less expensive all the time, of course.) However, having HIV doesn't guarantee progression to AIDS, and certainly schedules vary, especially if one takes preventative drugs. (Which, admittedly, cost money.)

But certainly exposure to HIV doesn't guarantee an HIV infection. And being raped doesn't guarantee even exposure to HIV.

So, at what point is an insurance company entitled to say that your increased risk allows them to throw you under the bus?

Elise said...

this is precisely the problem you're addressing.

Well, yes.

I don't think the bloggers who used this headline did so for revenue purposes. They did so to produce a particular emotional reaction.

Elise said...

Beard - If it impossible for Susan to be infected with HIV and show no signs of it for 3 years then the insurance company has made a medical mistake - as I discussed in my post.

If it possible for Susan to have latent undetectable HIV - an assumption I explicitly made - then all the insurance company knows is that they are confronted with an applicant who has taken HIV meds in the very recent past. They have no way of knowing the circumstances which caused her to take them and so it is reasonable for the insurance company to assume that Susan reasonably believed she had been exposed to HIV.

Figment and Reality said...

If we follow the conclusion of the insurance company, it would be best if she bought the drugs on the black market to prevent being labelled with the pre-existing condition tag. Should she later discover she indeed contracted HIV, then since they did not know about it, they would be required to cover it. Instead, by being responsible, she is being penalized.

She had to go to a Doctor to get the prescription, he/she recommended the meds as Prophylactic care and she is now being told that her potential exposure is now a pre-existing condition and obviously did not have insurance at the time of the Rape. She could have ignored the potential problem, and she would be covered, but theoretically dead sooner because she wasn't being responsible for her health safety.

From what I read, the one very important part of any health plan discussion has to be true portability. With portability, pre-existing doesn't occur, as long as you don't have insurance lapses. That was the intent of COBRA but it does not work as applied when the premiums under COBRA exceed your unemployment check. Of course, if you don't have pre-existing limits, then portability is irrelevant.

As far as the media playing to their audience, what else can we expect? They are rewarded financially by having larger audiences and our world runs on money. The headline caught me, just like the rest of us in this blog. If they (or you) had changed the title, few would listen or read about it. There is truth to the theory that "if it bleeds, it leads" in the newroom. Profits are what keep the news companies running but it is unfortunate that opionions get confused with real news.

Thanks for the insightful commentary.

Elise said...

Figment and Reality - I started a response and it grew into a post. It's up now called - cleverly - "Figment and reality".

Thanks for helping me crystallize some of my thoughts.