Americans might assume that now that Democrats have taken control of the House of Representatives, that there will be little change to the Affordable Care Act (ACA). But the issue remains live due to a pending multi-state lawsuit, Texas v. United States, that could reverse the ACA’s protections for pre-existing conditions.
Most Republican candidates failed to adequately address the issue of pre-existing conditions ahead of the midterm elections and for this they paid a political price. Voters said they trusted Democrats more on pre-existing conditions than Republicans (58-34 percent) and health-care voters broke for Democrats 3-to-1. The GOP sorely needs to demonstrate leadership on the issue of pre-existing conditions, not just by rejecting the ACA, but by offering a better solution.
Some Republicans want to repeal other parts of the ACA but embrace its rules about pre-existing conditions. This would be a mistake.
For one thing, it’s a bad political strategy: All of the GOP bills floated in 2017 to repeal and replace the ACA kept the law’s protections for pre-existing conditions and for this, Republicans got no credit.
No matter what Republicans do to try to keep the ACA’s rules in place, their efforts will be depicted as a fraudulent promise and/or shallow political gamesmanship. However unfair, the Democrats’ narrative (featured prominently in the media) is never going to acknowledge Republican efforts on pre-existing conditions, although there’s only one party who has ever taken private insurance options away from millions of Americans and it’s not the GOP.
Not only are the ACA’s rules on pre-existing conditions a political trap for Republicans, but they are bad policy: Instead of fighting on the left’s terms, Republicans should abandon the ACA’s misguided rules — rules that have benefitted very few and harmed many more — and instead focus on supporting those who really need it without distorting the entire marketplace.
The Obama administration and others claimed that 129 million Americans would be protected by the ACA's rules about pre-existing conditions, but this gross misrepresentation earned “Four Pinocchios” from the Washington Post fact checker. Because the vast majority of Americans have insurance either through work or through Medicare or Medicaid, data show that only about 500,000 people, or less than 0.2 percent of the U.S. population, could not access a health plan due to their pre-existing condition before the ACA.
To help this group of people, the ACA fundamentally transformed health insurance. Traditionally, insurance — in any context — is a backstop against unexpected costs. We buy car insurance to protect us financially in the event of damage to our cars. Similarly, we buy homeowner’s insurance to insure against property damage or theft in our homes.
The ACA required health insurance companies to sell policies to everyone, even people with costly health conditions. This would be like requiring car or homeowner’s insurance companies to sell policies to people whose cars or homes have already been damaged or destroyed. Although a sick body and a totaled car are different in many important ways, they are similar in an insurance context: In both cases, the risk of high claims is certain. In any insurance market besides health care, we know it makes no sense to impose such requirements.
The designers of the ACA knew that forcing insurance companies to accept all applicants and offer the same premiums regardless of health status would be a good deal for people with costly conditions and a bad deal for everyone else. Without a mandate, relatively healthy people might choose to go uninsured until they needed coverage for medical claims and then they’d buy in.
Actually, this happened anyway, because the individual mandate and its penalty were weak and ineffective in the face of premiums that increased by over 100 percent in the law’s first three years. Healthier consumers were scared away, sicker consumers bought in, the pools got skewed,insurers faced financial losses and many exited the exchanges. What’s left? High costs and little choice.
If states win in Texas v. United States, it will be an overdue victory for the Constitution. And, as an added bonus, it will be an opportunity for the GOP to lead on pre-existing conditions. Working together with Democrats in the House, they should embrace a better policy solution, one that doesn’t wreak havoc on insurance for everyone and one that has meaningful benefit for both the healthy and the sick, such as state-based programs that provide direct financial aid to those with costly conditions, to make sure they can afford the care they need. This would be far better than doubling down on the failed framework established by the ACA.