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The word "unlimited" erased their care for life · Healthcare Scandal Investigations

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  Speaker 1: The document was two pages long. It listed everything your
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  Speaker 1: insurance would not cover.
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  Speaker 2: Most of it was ordinary.
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  Speaker 1: Language about deductibles, about networks, about which hospitals counted and
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  Speaker 1: which did not. But buried in the fine print, in
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  Speaker 1: a clause almost no one ever actually read before signing,
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  Speaker 1: sat a single word with no legal ceiling. Unlimited.
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  Speaker 2: Not one year. Not ten years. Unlimited. Unlimited.
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  Speaker 1: In Alaska, before the first day of 2014, a private
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  Speaker 1: health insurer could open your medical file, find a condition
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  Speaker 1: you had carried before you signed the policy, and exclude
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  Speaker 1: it from your coverage for as long as the company
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  Speaker 1: chose to.
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  Speaker 2: Forever, if it wanted to.
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  Speaker 1: You would keep paying the premium every month, the company
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  Speaker 1: would keep cashing the check, and the one thing you
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  Speaker 1: actually needed covered would simply not exist, as far as
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  Speaker 1: your policy was concerned. You would not find this out
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  Speaker 1: at your kitchen table, reading calmly. You would find it
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  Speaker 1: out in a billing office or on the phone with
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  Speaker 1: a claims adjuster, holding a piece of paper that suddenly
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  Speaker 1: meant something different than you thought it meant. Alaska was
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  Speaker 1: not an outlier.
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  Speaker 2: It was one of.
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  Speaker 1: 10 states where that single word carried the full force
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  Speaker 1: of law. Somewhere near 50 million Americans were living inside
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  Speaker 1: that word, and most of them did not know it.
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  Speaker 1: This is the story of the clause that outlasted their
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  Speaker 1: attention and what it actually cost the people who only
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  Speaker 1: found it on the day they needed it most. To
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  Speaker 1: understand what pre-existing condition meant in practice, you have to
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  Speaker 1: accept something uncomfortable first. It did not mean one thing.
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  Speaker 1: There was no single federal definition of it anywhere in
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  Speaker 1: the country. The meaning shifted by state, by insurer, and
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  Speaker 1: sometimes by one clause buried inside a single individual policy.
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  Speaker 1: A condition that qualified for full coverage in Ohio could
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  Speaker 1: trigger a permanent exclusion 60 miles away on the other
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  Speaker 1: side of the Indiana line for no reason except which
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  Speaker 1: side of a map you happen to live on. Two
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  Speaker 1: competing legal tests governed most of the country before 2014.
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  Speaker 1: The first was the objective standard. Under it, a condition
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  Speaker 1: counted as pre-existing only if a doctor had actually diagnosed
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  Speaker 1: or treated it before your coverage began.
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  Speaker 2: There was a record. There was a name for it.
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  Speaker 2: It sounds fair.
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  Speaker 1: It sounds like something a person could plan around if
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  Speaker 1: they knew the rule. The second test did not work
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  Speaker 1: that way. It was called the prudent person's standard. Under it,
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  Speaker 1: a condition was pre-existing if your symptoms were serious enough
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  Speaker 1: that a reasonably careful person would have gone to see
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  Speaker 1: a doctor about them.
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  Speaker 2: Whether or not you actually went.
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  Speaker 1: No diagnosis required. No doctor's note required. No test result required.
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  Speaker 1: The mild ache in your chest that you decided was nothing.
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  Speaker 1: A headache that came and went for a week in
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  Speaker 1: October and then stopped. A shortness of breath you blamed
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  Speaker 1: on stress and never mentioned to a single person. If
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  Speaker 1: those symptoms existed before your policy started, and an insurer
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  Speaker 1: later decided that a reasonable person would have sought care
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  Speaker 1: for them, your claim could be denied on that basis alone.
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  Speaker 1: Built entirely on a doctor's visit that never happened. There
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  Speaker 1: was no appointment to look up, no prescription, no test
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  Speaker 1: result to argue with. There was only an insurer's opinion
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  Speaker 1: about what you should have done, applied backward, after the fact,
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  Speaker 1: to decide what they now owed you. You could not
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  Speaker 1: defend yourself against a diagnosis that never happened. You could
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  Speaker 1: only listen while someone who had never met you explained
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  Speaker 1: what you, personally, should have felt in your own chest,
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  Speaker 1: on a specific afternoon, months or years before either of
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  Speaker 1: you had ever heard of the other. The condition did
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  Speaker 1: not need to be serious to qualify. That was the
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  Speaker 1: part most people never expected. Tonsillitis, acne, seasonal allergies, toenail fungus, bunions.
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  Speaker 1: These were not hypothetical categories invented for a congressional hearing.
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  Speaker 1: They were documented grounds insurers had actually used in practice
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  Speaker 1: to deny or limit real claims from real people. One
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  Speaker 1: dermatology visit in your 20s, for something as minor as acne,
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  Speaker 1: could follow you for the rest of your life, quietly
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  Speaker 1: written out of every policy you would ever buy afterward.
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  Speaker 1: Not because the condition mattered, because the file existed. Nobody
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  Speaker 1: warned you, at the time, that the visit itself was
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  Speaker 1: the thing being recorded.
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  Speaker 2: You went in for acne.
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  Speaker 1: What the system kept was a fact about you that
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  Speaker 1: would outlive the acne by decades. The fine print had
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  Speaker 1: a long memory, and it never once forgot. That architecture
• 4:30
  Speaker 1: went back to 1945, when the McCarran-Ferguson Act handed the
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  Speaker 1: regulation of insurance to the states instead of to the
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  Speaker 1: federal government. 50 legislatures wrote 50 separate rulebooks, with nothing
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  Speaker 1: requiring any of them to agree with each other, or
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  Speaker 1: even to talk to one another. The patchwork that followed
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  Speaker 1: was not an accident of history. It was the design.
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  Speaker 1: By 1996, Congress tried to close part of the gap.
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  Speaker 1: The Health Insurance Portability and Accountability Act, known as HIPAA,
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  Speaker 1: capped exclusion periods at 12 months for people covered through
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  Speaker 1: an employer's group health plan. For someone with a steady
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  Speaker 1: job and workplace insurance, that was a real, meaningful protection.
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  Speaker 1: It shrank a problem that had once had no edges
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  Speaker 1: at all down to something you could count on a calendar.
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  Speaker 1: But HIPAA never touched the individual market. Anyone who bought
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  Speaker 1: a plan on their own, a freelancer, a part-time worker,
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  Speaker 1: someone between jobs, someone whose employer simply offered nothing, got
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  Speaker 1: none of that protection. In that market, the old rules
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  Speaker 1: kept running exactly as they had for 50 years, untouched
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  Speaker 1: by the one law most people assumed had already fixed this.
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  Speaker 1: Congress had already proven, in 1996, that it knew exactly
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  Speaker 1: how to write a 12-month limit into federal law. The
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  Speaker 1: mechanism existed. It simply stopped at the office door. If
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  Speaker 1: your coverage came with a job, the fix applied to you.
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  Speaker 1: If it did not, you were still living under the
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  Speaker 1: old rules, in the same country, under the same Congress
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  Speaker 1: that had just decided you didn't count. In Indiana, an
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  Speaker 1: insurer could impose a 10-year exclusion.
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  Speaker 2: On an individual policy.
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  Speaker 1: 10 years.
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  Speaker 2: Is not a waiting period.
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  Speaker 1: Ten years is most of a decade spent paying premiums
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  Speaker 1: for coverage that does not cover the one thing you
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  Speaker 1: actually have. And in ten states, Alaska, Arizona, Arkansas, Delaware,
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  Speaker 1: the District of Columbia, Louisiana, Mississippi, New York, Virginia, and Wyoming,
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  Speaker 1: there was no ceiling at all. Insurers there could exclude
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  Speaker 1: a pre-existing condition indefinitely, for life. A person diagnosed young
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  Speaker 1: could still be paying for that same policy decades later,
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  Speaker 1: and the one condition they actually needed help with would
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  Speaker 1: remain the one condition the policy had promised, in advance,
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  Speaker 1: never to pay for. 37 states allowed something even more
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  Speaker 1: permanent than a long waiting period.
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  Speaker 2: It was called an elimination rider.
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  Speaker 1: A clause added to an individual policy that carved out
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  Speaker 1: one specific body part or condition and excluded it forever.
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  Speaker 1: Not for a waiting period. Not for 10 years. For
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  Speaker 1: as long as you held the policy, full stop. The
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  Speaker 1: person with a history of knee problems could be sold
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  Speaker 1: a plan that would never, under any circumstance, pay for
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  Speaker 1: anything to do with that knee, no matter how many
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  Speaker 1: years passed or how many premiums were paid on time.
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  Speaker 1: They were buying insurance with a hole already cut into it,
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  Speaker 1: and signing their own name directly underneath the hole. The
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  Speaker 1: rider did not announce itself in plain language. It sat
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  Speaker 1: among dozens of other clauses, in the same dense type
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  Speaker 1: as the deductible and the copay, indistinguishable at a glance
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  Speaker 1: from the ordinary parts of the contract. You could read
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  Speaker 1: the whole document and still miss the one line that
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  Speaker 1: mattered most. because it was written to look exactly like
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  Speaker 1: everything around it. Where you happen to live decided which
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  Speaker 1: version of this system applied to you. Your address, more
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  Speaker 1: than your actual health, determined whether a childhood illness could
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  Speaker 1: reach forward through the decades into your 40s and quietly
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  Speaker 1: close a door you believed you had already paid, every month,
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  Speaker 1: to keep open. There's one entry on that list of
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  Speaker 1: excludable histories that made even people inside the insurance industry
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  Speaker 1: uncomfortable to discuss out loud. Picture a specific kind of afternoon,
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  Speaker 1: A woman leaves a relationship that hurt her. She does
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  Speaker 1: the thing every doctor, every hotline, every public health campaign
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  Speaker 1: in the country has told her to do. She goes in,
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  Speaker 1: and she gets treated. The visit gets written down, because
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  Speaker 1: that is simply what visits do. It becomes a line
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  Speaker 1: in a chart, a code in a file, a fact
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  Speaker 1: that now exists permanently on paper, filed somewhere she will
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  Speaker 1: probably never see again. Years later, she is not covered
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  Speaker 1: through a job, so she applies for her own individual
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  Speaker 1: health insurance. She answers the medical history questions honestly, because
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  Speaker 1: lying on the application is fraud, and she is not
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  Speaker 1: the kind of person who lies. And because she answered honestly,
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  Speaker 1: the insurer now has that line in front of them.
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  Speaker 1: In several states, a documented history of treatment following domestic
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  Speaker 1: violence could be classified, on an insurance application, as a
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  Speaker 1: pre-existing condition. Sit with what that actually produces. The rule
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  Speaker 1: that defined pre-existing conditions said, a reasonable person would have
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  Speaker 1: sought treatment for something serious.
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  Speaker 2: She sought treatment.
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  Speaker 1: She did exactly what a reasonable person does when they
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  Speaker 1: are hurt. And the system then took the record of
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  Speaker 1: her doing the reasonable thing and used it as the
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  Speaker 1: reason to deny her.
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  Speaker 2: The rule rewarded silence.
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  Speaker 1: It punished the simple paperwork of getting help. Some women,
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  Speaker 1: running that calculation quietly in their own heads, decided the
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  Speaker 1: record itself was a risk they could not afford to create,
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  Speaker 1: not because they didn't want the care, because the cost
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  Speaker 1: of documenting it might end up outlasting the injury itself
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  Speaker 1: waiting in a file for a moment years away that
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  Speaker 1: they could not yet see coming. Think about what that
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  Speaker 1: asks of a person in the exact moment they are
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  Speaker 1: most in need of help. It asks them to weigh
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  Speaker 1: a future insurance application against a present injury and to understand, correctly,
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  Speaker 1: that the paperwork could someday be turned against them. That
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  Speaker 1: is not a hypothetical burden. That is a fact about
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  Speaker 1: how the system was built, sitting quietly underneath a decision
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  Speaker 1: no one should.
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  Speaker 2: Have to make twice.
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  Speaker 1: When this particular practice reached the public, one of the
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  Speaker 1: loudest responses came from inside the industry itself. Basia Natan,
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  Speaker 1: who worked in sales and marketing at State Farm, later
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  Speaker 1: described the company's reaction when the domestic violence exclusion.
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  Speaker 2: Was brought to its attention. His words were direct. We
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  Speaker 2: wanted no part of that.
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  Speaker 1: Sit with that sentence for a moment. It is not
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  Speaker 1: a regulator speaking from outside the industry looking in. It
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  Speaker 1: is not an advocate. It is someone who sold insurance
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  Speaker 1: for a living, telling the public, on the record, that
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  Speaker 1: his own industry had gone somewhere he personally refused to follow.
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  Speaker 1: It is a small, human refusal, sitting inside a very large,
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  Speaker 1: very cold machine. And it matters, because it means the
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  Speaker 1: people running these companies knew exactly what the fine print
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  Speaker 1: was doing to actual people. They simply did not all agree,
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  Speaker 1: among themselves, that it should keep doing it. That disagreement
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  Speaker 1: is a kind of hope, even inside a story this cold.
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  Speaker 1: The industry was not one monolith quietly nodding along. Somewhere
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  Speaker 1: inside it, Someone looked at what the rule permitted and
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  Speaker 1: said no, not this one, out loud, where it could
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  Speaker 1: be quoted. The public, for its part, had already made
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  Speaker 1: up its mind, and had made it up a long
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  Speaker 1: time before anyone in Washington acted on it. Polling conducted
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  Speaker 1: before the reform legislation passed found that roughly 80% of
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  Speaker 1: Americans supported requiring insurers to cover people with pre-existing conditions.
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  Speaker 1: That support did not split cleanly along party lines, the
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  Speaker 1: way almost everything else in that era did. 67% of
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  Speaker 1: Republicans backed it too. 80% is not a narrow majority.
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  Speaker 1: 80% is closer to consensus than American politics manages to
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  Speaker 1: produce on almost anything else you could name. The system
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  Speaker 1: that had existed for six decades was not something the
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  Speaker 1: public had ever actually chosen. It had been assembled quietly,
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  Speaker 1: one state legislature at a time, far from the kind
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  Speaker 1: of attention that 80% of the country turned out to
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  Speaker 1: be capable of once the question was finally put to
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  Speaker 1: them directly. It was something that had simply never been asked,
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  Speaker 1: out loud, to justify itself.
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  Speaker 2: Until, finally, it was.
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  Speaker 1: On March 23, 2010, the Affordable Care Act became law.
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  Speaker 1: The full prohibition on pre-existing condition exclusions did not take
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  Speaker 1: effect immediately. It took effect on January 1, 2014, nearly
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  Speaker 1: four years later, after insurers had time to prepare for
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  Speaker 1: a market that would look nothing like the one they
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  Speaker 1: had built. After that date, No insurer operating anywhere in
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  Speaker 1: the United States could legally deny coverage or impose an
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  Speaker 1: exclusion period based on a pre-existing condition. Not in the
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  Speaker 1: individual market. Not in the group market. The word unlimited
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  Speaker 1: stopped being legal. The Kaiser Family Foundation analysis, published in 2016,
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  Speaker 1: tried to measure what the old system had actually been
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  Speaker 1: hiding underneath all that fine print.
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  Speaker 2: The number it found was 52 million.
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  Speaker 1: 52 million Americans under the age of 65, more than
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  Speaker 1: one in four adults in the country, carried a condition that,
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  Speaker 1: under the prior rules, would have qualified them for exclusion
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  Speaker 1: or outright denial.
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  Speaker 2: Heart disease. Diabetes. A history of cancer.
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  Speaker 1: An old injury from years earlier that had never fully
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  Speaker 1: explained itself. A single visit to a doctor once that
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  Speaker 1: created one line in one file and was then forgotten
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  Speaker 1: by everyone except the insurance system. Most of those 52
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  Speaker 1: million people never once read the word unlimited printed anywhere
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  Speaker 1: in their own policy. They only met it at the
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  Speaker 1: worst possible moment, filing a claim in a hospital hallway
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  Speaker 1: or over a kitchen table, learning for the first time
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  Speaker 1: exactly what their coverage had never actually included. 52 million
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  Speaker 1: is larger than the population of most countries on earth.
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  Speaker 1: It is not a statistic about a fringe group living
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  Speaker 1: at the edge of the system. It is a statistic
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  Speaker 1: about more than one in four adults under 65.
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  Speaker 2: Which means it was never really a story about them.
• 13:40
  Speaker 1: It was a story about the country as a whole,
• 13:42
  Speaker 1: discovering piece by piece what its own insurance market had
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  Speaker 1: quietly agreed to leave out. Here's the part of this
• 13:48
  Speaker 1: story that is easiest to miss, and the part worth
• 13:50
  Speaker 1: sitting with the longest. The prohibition that took effect in
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  Speaker 1: 2014 changed the clause. It did not change the machinery
• 13:58
  Speaker 1: that had produced the clause in the first place. The
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  Speaker 1: McCarran Ferguson Act still hands insurance regulation to 50 separate states,
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  Speaker 1: right now, today. The habit of writing coverage in language
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  Speaker 1: that only reveals itself under a magnifying glass was never
• 14:11
  Speaker 1: actually made illegal in general. It was only pointed, for
• 14:14
  Speaker 1: the time being, in a different direction on this one
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  Speaker 1: specific question. The 52 million people that Claus used to
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  Speaker 1: describe did not disappear the moment the law changed. They
• 14:24
  Speaker 1: are still out there, still carrying the same diagnoses, the
• 14:27
  Speaker 1: same old injuries, the same single lines sitting in the
• 14:30
  Speaker 1: same old files. What changed is not their bodies. What
• 14:35
  Speaker 1: changed is only whether the law currently requires someone to
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  Speaker 1: cover them anyway.
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  Speaker 2: You may be one of them. Right now. And not
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  Speaker 2: know it.
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  Speaker 1: The same way most of the 52 million did not
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  Speaker 1: know it, until the specific year the ceiling itself was
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  Speaker 1: finally tested. Think for a moment about your own file.
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  Speaker 1: An old sprain. A cholesterol number a doctor once mentioned
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  Speaker 1: in passing. A visit you barely remember making. Somewhere, a
• 15:00
  Speaker 1: version of you exists on paper, and for most of
• 15:02
  Speaker 1: the 20th century, that paper version was the one insurers
• 15:05
  Speaker 1: were actually willing to insure. Or not.
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  Speaker 2: K.C.
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  Speaker 1: Einaten. said his own company wanted no part of a
• 15:11
  Speaker 1: system that used a woman's trip to a doctor as
• 15:13
  Speaker 1: a weapon against her. 80% of the country, when asked
• 15:17
  Speaker 1: plainly and directly, agreed with him. It took 69 years,
• 15:21
  Speaker 1: from a quiet regulatory handoff in 1945, to a prohibition
• 15:25
  Speaker 1: that finally took effect in 2014, for that agreement to
• 15:28
  Speaker 1: become enforceable law. The distance between what people say they
• 15:32
  Speaker 1: want and what a system quietly keeps doing anyway can
• 15:35
  Speaker 1: run for decades before anyone actually closes it. In this case,
• 15:39
  Speaker 1: It ran for roughly 60 years before it closed. The
• 15:42
  Speaker 1: clause is gone today because the law currently requires its absence.
• 15:47
  Speaker 1: Laws can be amended. The habit of writing unlimited into
• 15:51
  Speaker 1: fine print that almost no one ever reads was never,
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  Speaker 1: in itself, illegal. It was only for one long stretch
• 15:58
  Speaker 1: of American history, unpopular enough with the people living under it,
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  Speaker 1: to finally be stopped. The document was two pages long,
• 16:06
  Speaker 1: somewhere in a filing cabinet or a folder on a
• 16:08
  Speaker 1: hard drive, An older version of that document still exists,
• 16:11
  Speaker 1: with that same word still sitting in the same fine print,
• 16:14
  Speaker 1: describing a system that, for now, the law no longer allows.
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  Speaker 1: This show is made by Obo Media.