PolitiFact: Would Kimmel's newborn really not be covered?

Jimmy Kimmel's intensely personal tale last week of his newborn son's emergency — and successful — heart surgery came with a potent policy message. After thanking the people who pulled his son back from the brink, the late night host defended the Affordable Care Act against Republican efforts to do away with it.

"Before 2014, if you were born with congenital heart disease like my son was, there was a good chance you'd never be able to get health insurance because you had a preexisting condition," Kimmel said. "You were born with a preexisting condition. And if your parents didn't have medical insurance, you might not live long enough to even get denied because of a preexisting condition.

"If your baby is going to die, and it doesn't have to, it shouldn't matter how much money you make. I think that's something that, whether you're a Republican or a Democrat or something else, we all agree on that, right?"

The Affordable Care Act struck a core deal with insurance companies. It required pretty much everyone to have insurance, but in exchange, it prohibited insurance companies from denying policies to people with health problems. Republican leaders have said their new bill protects people with preexisting conditions, but some lawmakers challenge that.

Kimmel's story raises several policy questions, and we'll unpack them.

The health policy experts we reached told us that, no matter what, a newborn who needed emergency surgery would get it.

Under the 1986 Emergency Medical Treatment and Labor Act, hospitals must treat and stabilize anyone in a health crisis, regardless of ability to pay.

As with many health care issues, the answer depends on a number of factors.

Both today and before the ACA, if the family's income is low enough, the child could be enrolled in Medicaid. The federal Children's Health Insurance Program provided coverage for families making above the poverty line (how much above would vary from state to state). Importantly, as Medicaid analyst MaryBeth Musumeci at the Kaiser Family Foundation told us, "coverage goes retroactive to the month of application plus three months prior."

Musumeci added that if the child had severe, long-term care needs, Medicaid coverage would protect the family from high bills, regardless of income.

But what if the family had no insurance and made too much for Medicaid?

"The hospital and medical providers would bill them directly for their newborn's care," said Georgetown University health policy researcher Sabrina Corlette. "Most people would not be able to afford those bills, which helps explain why medical debt was one of the leading causes of personal bankruptcy, pre-ACA."

With millions more people insured through the Affordable Care Act, the uncompensated-care problem has fallen to its lowest level in decades.

Gerald Kominski, professor of health policy and management at UCLA, said that even if the parents had insurance, they might still be caught short.

"The parents might have annual or lifetime limits on benefits, and might exceed those limits rapidly with a seriously ill child, so they'd run out of benefits legally," Kominski said. "That cannot happen under the ACA."

Obamacare prohibited those limits.

Kimmel said that with someone like his son, before Obamacare, "there was a good chance you'd never be able to get health insurance because you had a preexisting condition."

When the child turned 18 or whatever age made him a legal adult, insurance companies could deny him coverage.

"The only protection would be if the person lived in a state that prohibited preexisting condition exclusions," said Kominski.

Another possibility was that someone with a preexisting condition could get insurance through a "high-risk pool," where states would underwrite the cost of insurance for people with significant health issues. But the availability and cost varied from state to state.

So what might happen to the newborn and the family's coverage while the child was young?

Before the Affordable Care Act, even having insurance was not foolproof. We found two cases in which parents saw their newborn's claims denied because their insurance companies treated the baby's problems as a preexisting condition. One took place in Arizona in 2005 and the other in Texas in 2010.

"The hospital is only required to provide care if the baby comes into the emergency room in cardiac arrest," Pollitz said. "Otherwise, it would be considered a scheduled surgery and they would have no obligation to provide treatment."

Pollitz said parents in the non-group market — the slice of the market now included in the ACA exchanges — faced another threat.

"They would tend to find that their rates would climb dramatically at renewals," Pollitz said. "The insurance companies weren't supposed to do it, but they had ways. If you were a parent of a child with a preexisting condition, it was hard to stay covered. The premiums would become unaffordable."

Under the Affordable Care Act, Pollitz said rates might rise more broadly, but families with an ill child are no longer singled out.

Near the end of his monologue, Kimmel made the point that no child should die because he or she was born with a dangerous but treatable condition but didn't have insurance.

But without insurance, and sometimes even with insurance, before the Affordable Care Act, the path ahead could be rocky indeed.