Image: Shutterstock.com/ J Dennis

Getting insurance coverage for fibromyalgia is difficult. And it’s especially difficult when insurance companies can disqualify you for coverage based on pre existing conditions. So how does the idea of pre-existing conditions work exactly? Does fibromyalgia fall under the category of pre existing conditions? And how will your insurance for fibromyalgia change under the new law?

How Do Pre existing Conditions Work?

Insurance companies exist to turn a profit and the fact that Americans overwhelmingly rely on private insurance companies to pay for life-saving treatment doesn’t change that. So insurance companies want to pull in as much in premiums as they can and pay out as little in claims as possible.

So one of the methods they use to avoid paying out premiums is to disqualify people based on pre existing conditions. If you buy insurance and then later get sick, the insurance company can deny your claim based on the logic that you actually had the condition before you got the insurance.

But they can also refuse to cover you at all or charge you a higher if you have one of a large number of pre-existing conditions. This lets them avoid having to insure people who will end up costing them more money than they pull in. It’s one of the aspects of paying for health care in America that makes it such a nightmare for a lot of people.

And recently, it’s become even more complicated because of the political situation. Under the Affordable Care Act, there are restrictions on how much more insurers can charge people with pre existing conditions. With the Republicans promising to repeal the ACA and replace it with the American Health Care Act, this may no longer be the case soon.

Under the proposed American Health Care Act, insurers are to be allowed to both deny people coverage based on pre-existing conditions and to charge more for the same coverage if the insured has one. In addition, the things that they consider pre-existing conditions have expanded considerably. Things like transsexualism and mental health issues are now considered pre-existing conditions under the AHCA.

Is Fibromyalgia A Pre-existing Condition?

Nearly every insurance company considers fibromyalgia to qualify as a pre-existing condition. And fibromyalgia can be an expensive condition, both to the insurance companies and to the patient. Some have estimated that the total economic cost of fibromyalgia runs into the billions.

And the average fibromyalgia patient will spend at least a few thousand dollars a year in insurance co-pays, assuming that they have insurance. If not, all that cost will come out of pocket and can cost tens of thousands a year. So getting coverage for fibromyalgia has always been difficult.

But it isn’t just difficult to get medical insurance either. Around a quarter of fibromyalgia patients get disability payments, which means that getting disability insurance as someone with fibromyalgia is difficult. Insurance companies know that people with fibromyalgia are likely to need disability payments at some point and are reluctant to cover them.

And the law is likely to change soon in a way that makes it even harder for people with fibromyalgia to get insurance.

How Will Your Coverage Change?

Under the Affordable Care Act, insurers are required to cover the costs of treatment for pre-existing conditions like fibromyalgia. But under the proposed American Health Care Act, it’s not clear if this will continue to be the case. Paul Ryan recently tweeted that a proposed amendment to the Act would protect people with pre-existing conditions. But that is subject to change and it isn’t clear exactly how much protection for pre-existing conditions the amendment would provide.

At the moment, the Affordable Care Act remains in place. The house of representatives have voted to repeal it, but the repeal has yet to pass through the Senate. Proponents of repealing the ACA argue that the lack of government regulation will allow the free market to drive down insurance costs for everyone. And there’s some truth in the argument that the ACA did make insurance more expensive for some people. But it also made it possible for people with health problems to actually get insurance.

And there’s little doubt that the protections of the ACA for pre-existing conditions will likely be scaled back under any conceivable Republican-led replacement.

That means that the average fibromyalgia patient will likely have to pay more in insurance premiums and out of pocket co-pays once the ACA is repealed. It’s not set in stone of course. And it is possible that Congress will be able to work out a plan that protects people with pre-existing conditions like fibromyalgia and drives down costs for everyone as they have promised.

But it probably isn’t worth holding your breath for, since a plan that lowers costs and expands coverage is something of the Holy Grail of healthcare reform and the AHCA doesn’t seem to fit the description so far.

Tell us, though. Do you like the American Health Care Act? Do you want to stick with the ACA? Have you had trouble getting insurance with fibromyalgia? Let us know in the comments.