TMC PULSE

t m c » p u l s e | j u n e 2 0 1 7 25 My Favorite Patient Died Because She Had a Pre-Existing Condition B y A r t h u r G a r s o n J r . , M . D . , M . P . H . M y favorite patient was born with the same con- genital heart condition as Jimmy Kimmel's son and had exactly the outcome that Kimmel predicted. My first night as a pediatric cardiology trainee, I helped care for a 5-year-old who had just had surgery for her heart problem, Tetralogy of Fallot with pulmo- nary atresia. She had been a blue baby; because of her heart condition, blood had trouble flowing to her lungs to pick up oxygen for her body. Her heart stopped three times, and three times I went to tell her parents and grandparents that I did not think she would make it. But she did—and we all bonded. I went to her graduation ceremonies from gram- mar school and high school. She became a wonderful young adult with a phenomenal sense of humor. She was not able to do physical work, but was capable of desk jobs. Although she developed a dangerous irregular heartbeat, we were able to control it with medication. Her parents had few resources, yet she was covered by Medicaid. But six months to the day after her 19th birthday, her mother called barely able to speak: They had found her dead in bed. They did some checking and she had not refilled a prescription for her medication—after her Medicaid ran out—six months previously. She had a pre-existing condition that no one in her small town would cover, and there were no large employers. This experience devastated all of us and made me go back and get a degree in public health, with the goal of helping the uninsured. This was the situation 27 years ago. For the past seven years, however, the Affordable Care Act (ACA)—also known as Obamacare—covered pre-existing conditions. Although the ACA surely has its failings and needs major surgery, many people with pre-existing conditions got access to health care. Prior to that, between 2007 and 2009, a Congressional investigation of the four largest insurance companies found that 651,000 people were denied coverage—one of every seven who applied—because of pre-existing conditions. All perfectly legal. The pre-existing condi- tion exclusion was the only "stimulus" to have healthy people buy insurance. And it worked. While this was a horrendous provision, it was effective: healthy people did buy insurance. The American Health Care Act (AHCA) that passed the House of Representatives in early May allows each state to apply to the federal government to permit pre-existing condition exclusions, as long as they do one of the following: "reduce average premiums for health insurance coverage in the State; increase enrollment in health insurance coverage; increase the choice of health plans in the State." Imagine how easy it will be for the state to add just one health plan and meet the criteria, thus allowing pre-existing exclusions. The bill also requires that states that allow pre-existing exclusions have in place ways to help people with pre-existing conditions, such as high-risk pools allowing people with high medical expenses to be paid for separately. Texas has a high-risk pool, but only 2.6 percent of eligible people actually participate. Why? The rates are higher than current insurance rates, which people can't afford to begin with, and the pre-existing condi- tion exclusion requires the ill person wait a year before coverage. No wonder people don't sign up for high-risk pools. A number of U.S. members of Congress from both sides of the aisle have said after the passage of the bill in the House, which is projected to add 23 million people to the ranks of the uninsured, they expect the Senate to fix everything. This is similar to the House jumping out of a plane without a parachute and expecting the Senate to rescue it and guide the both of them to safety. I surely hope the Senate has a strong para- chute. My patient would have been alive under the Affordable Care Act and dead with the recent legislation. Arthur "Tim" Garson Jr., M.D., M.P.H., is director of the Texas Medical Center's Health Policy Institute. Jimmy Kimmel, right, host of Jimmy Kimmel Live on ABC, listens as Dr. Mehmet Oz explains the heart condition affecting Kimmel's infant son, Billy. Tetralogy of Fallot with pulmonary atresia is a condition that includes a malformed pulmonary valve and a hole in the tissue between the lower chambers of the heart. Credit: By Randy Holmes/Getty Images

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