Last week the federal departments of Health and Human Services, Labor, and Treasury “released interim final regulations implementing five of the insurance enrollee protections of the Patient Protection and Affordable Care Act” (the official name for the health insurance reform law adopted in March). Timothy Jost analyzed the regulations for the Health Affairs blog, and his whole post is worth reading. While a lot of uncertainty surrounds the new rules, the cost of compliance is expected to be low. Jost finds that “[r]elatively few people will directly benefit” from the health insurance reform, but there will be “[l]arge benefits for those who are affected.”

During the last presidential campaign and more than a year of health care debates on Capitol Hill, countless politicians swore they were committed to ending discrimination against Americans who have pre-existing medical conditions. After reviewing the interim regulations, Jost has good news and bad news for adults who lack health insurance because of a medical problem.

The ban on preexisting conditions exclusion found in the Affordable Care Act is much broader than the preexisting condition exclusion imposed by the Health Insurance Portability and Accountability Act [of 1996].  It prohibits any limitation or exclusion of benefits in a group or individual plan based on the prior existence of a medical condition.  The provision not only prohibits the exclusion of coverage of specific benefits based on a preexisting condition, but also the complete exclusion from the plan of a particular person if the exclusion is based on a preexisting condition.   The regulation does not, however, prohibit coverage exclusions that apply regardless of whether a condition is a preexisting condition or not.   The provision applies to enrollees under the age of 19 effective the first plan year beginning after September 23, 2010, but to adults only beginning in 2014.

In the summer of 2009, many progressives were disturbed to learn that the draft House health care bill delayed implementation of the pre-existing condition provision until 2013 (the date was pushed back to 2014 later in the legislative process). Why should Americans with previous or chronic medical problems continue to be denied health insurance for four more years? Don’t worry, we were told: new high-risk pools will be created to bridge the gap for people with pre-existing conditions.

We are now learning more about how the new Pre-Existing Condition Insurance Plan will operate. Eligible Iowans will be able to start applying for our state’s plan on July 15. But uh oh:

The new program, expected to start in a few weeks, will be financed with $35 million in federal money from the new health care reform law. That money will be enough to help only 975 Iowans, state administrators have concluded.

“$35 million doesn’t cover as many people as you’d hope,” said Susan Voss, Iowa’s insurance commissioner.

Another twist is that Iowans who participate in the state’s current high-risk insurance pool won’t be able to switch into the new pool, which will be significantly less expensive.

Federal experts have estimated that 34,500 Iowans could be eligible for the new pool.

The money is supposed to last until 2014, when private insurers will be banned from discriminating against people with pre-existing health conditions. At that point, such people should be able to buy their own insurance just like anyone else, health reform proponents say.

You see immediately what Jost was getting at: few Iowans with pre-existing conditions will benefit from the new high-risk pool (perhaps 3 percent of the eligible population). For those who get in, though, the benefits are immense: insurance for about the same price a healthy person would pay.

While helping 950 uninsurable Iowans obtain coverage is significant, it would have been better to implement the health insurance reform on a faster timetable. Because Congress lacked the political will to impose significant costs on insurance companies, 97 percent of Iowa adults with pre-existing conditions will have to wait until 2014 to reap the full benefit of the health reform.

That sounds like over-promising and under-delivering to me. But I can’t say I wasn’t warned a long time ago.

UPDATE: Democrats will talk up the health reform changes that take effect sooner, such as new Medicare reimbursement rates. Those are expected to increase payments to Iowa doctors and hospitals. But the public case for health care reform wasn’t built on wonky issues like Medicare reimbursement rates. It was a simple moral argument, and not letting insurers discriminate against people with a pre-existing condition was at its core.