Laurel to The Philadelphia Inquirer

For parsing preexisting conditions

A couple of decades ago, journalists at every paper and TV station, following the lead of The Wall Street Journal, began to personalize their reporting by starting with a little story that seemingly drew readers or viewers into the piece on their way to the nut graph. Maybe the anecdote illustrated the problem that the story was about to tell, or maybe it didn’t. Sometimes anecdotes missed the mark and offered false generalizations. Today, too many stories start with the likes of Dan and Barbara, the archetypical couple who maybe bought a mortgage they couldn’t afford, are over their heads in credit card debt, lost their health insurance, had to forego medical care, or used their tax refund to visit Barbados. We have abused the poor anecdote. They have become trite.

Michael Vitez, a staff writer at The Philadelphia Inquirer, who, over the last few months, has written a fine series about people without insurance, showed how an anecdote can be used well to demonstrate a larger issue. He scored with his lede, about a thirty-four-day-old baby named Nicholas Simon who was rejected by an insurance company because, on the fifth day of life, he had jaundice. Two days later he was perfectly normal, but the insurance company informed his parents: “We appreciate your interest in the Aetna Advantage Plans for Individuals and Families. After careful evaluation…we are unable to offer coverage and have declined your application.

Nicholas had fallen into insurance purgatory. His story illustrates the pitfalls of the individual insurance market, where people who have no group insurance must turn if they want coverage. A preexisting condition, even a minor one or one that has disappeared, can disqualify someone from coverage, leaving them to pay for care on their own.

Vitez talked to Aetna, whose spokesperson said that a high bilirubin count “can indicate an underlying liver condition.” (Bilurubin is the natural pigment that makes jaundice sufferers’ skin turn yellow.) She explained that if the company accepted babies like Nicholas, they would have to raise prices—perhaps to levels that other people couldn’t afford. All that is true, but actuarial principles hardly help those who don’t qualify for coverage.

Nicholas’s mother works for a small advocacy agency devoted to children and youth. Because health insurance is so costly for small employers—rising about 15 percent a year—the agency decided to buy a separate individual policy for Nicholas as way to lower its premiums. Nicholas was lucky, because his mom simply added him to her coverage at work. Others aren’t so lucky.

The anecdote drew me quickly into the story and clearly showed how preexisting conditions clauses work. Vitez covered some of the larger issues surrounding preexisting conditions clauses, at least in Pennsylvania. He reported that Gov. Ed Rendell had tried to pass a law prohibiting insurers from excluding Pennsylvanians with preexisting conditions. The bill passed the state House of Representatives but died in the Senate. No surprise.

Sam Marshall who heads the Insurance Federation of Pennsylvania, a trade group, told Vitez: “You don’t want people buying insurance only after they become sick. If there was no preexisting condition clause, we’d all wait and just sign up for insurance when we checked into the hospital.” He said his group helped kill the bill in part because coverage was not universal.

We wish Vitez had pursued this further, because the future of any federal health reform will turn on this point. America’s Health Insurance Plans, (AHIP), the industry’s national trade association, has said it would support some limits on preexisting conditions clauses, as long as the law requires everyone to buy health insurance. In other words, it might trade-off its members’ ability to cherry-pick the healthiest people in exchange for an individual mandate—an option that is bound to be super controversial. The Inky story briefly mentioned this point early on, but didn’t clearly connect it to a major flashpoint in the coming legislative battle, or to the legislative failure in Pennsylvania last year.

Instead it wasted two graphs on Gov. Bobby Jindal’s comments about his pregnant mother—who, when she arrived in America, couldn’t get insurance to cover his birth—and pointed out that Obama must clarify how he will make good on his campaign promises to eliminate preexisting conditions clauses. Once readers are sucked in with a good lede, they need someone to connect the dots in the right spot in the story. And they need to be shown how healthy thirty-four-day-old babies—or any other person, for that matter—will be helped or hurt by what’s on the legislative table.

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Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR's healthcare desk, which is part of our United States Project on the coverage of politics and policy. She also blogs for Health News Review. Follow her on Twitter @Trudy_Lieberman.