On Pre-Existing Conditions, Trump’s Words Have Differed From His Actions

While the president trumpets his desire to protect access to health care, his administration fights to do the opposite in court.

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One of the main strategies—arguably the main strategy—taken by Senate Democrats during the Senate confirmation hearings for Amy Coney Barrett has been to portray her as an existential threat to the Affordable Care Act. The attack hinges on Texas v. California, a lawsuit filed by 18 Republican state attorneys general that seeks to overturn the ACA. Oral arguments are scheduled for November 10.

The suit is widely considered to be a dead end, but Democrats’ political instincts to focus on a threat to Obamacare are correct. For example, the legislation’s provision forbidding insurance companies to deny coverage to people with pre-existing conditions is immensely popular: 72 percent of the public believes keeping the provision is “very important,” including 62 percent of Republicans. 

President Donald Trump has consistently said that those with pre-existing conditions would be covered in any plan that replaces Obamacare, even signing a (largely toothless) executive order declaring that those with pre-existing conditions would retain coverage in the event of an ACA repeal. He tweeted in June that he would “ALWAYS PROTECT PEOPLE WITH PRE-EXISTING CONDITIONS, ALWAYS, ALWAYS,ALWAYS”—typical of his public rhetoric on the matter. 

Yet while a majority of Republicans think that Trump would do a better job than Democrats on protecting those with pre-existing conditions, only 38 percent of the broader public agree with that claim. That dynamic was a crucial factor in Democrats’ widespread success in the 2018 midterm elections, where the story of their victory was less about much-hyped progressive insurgents and more a tale of moderates who consistently warned voters that Trump and the GOP were planning to take away their health care.

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  1. cb76

    The thing is, I don't think Trump understands what the ACA even does, or how it does (or does not) work. Not in the slightest. But it's got Obama's name on it, so by God, it must go.

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      Pat Riot

      What we have learned from Trump's popularity in the last five years is that perhaps 40% of American voters don't really care about policy of any kind. They care about the stock market and their team/culture "winning" and (just as importantly) the other side losing. (There's a qualitative study of Trump voters wherein most of them stated explicitly that they do *not* expect Trump's policies to help them in any personal way).

      Trump doesn't understand the ACA because he doesn't *have to* in order to get reelected...

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      1. cb76

        Agree with that, although I still question whether he could wrap his "very good brain" around it even if he thought it was in his interest to do so.

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      rlritt

      Totally agree. If he just the name without changing anything else he'd be happy. If you could change Roe vs.Wade to Trump vs Obama or Clinton, or any democrat he would probably defend it to the hilt.

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    Pat Riot

    Trump made it clear in the last debate that he hates Obamacare and he's glad his Supreme Court is working to overturn it. So Trump's words aren't contradicting his actions, Trump's words are pure gibberish along the lines of, "this sentence is false".

    The backdrop of Republicans being crushed in the polls right now is health care: even Trump "hard cores" are going to think twice about voting for somebody who could bring back those 50 page pre-existing conditions forms and/or denying them coverage so they have to sell the AR-15 collection in order to pay the doctor bills.

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  3. Doctor Mist

    What the heck happened to “continuous creditable coverage”?

    Guaranteeing coverage for pre-existing conditions never made any sense because of the adverse incentive to wait until you are sick before seeking coverage. That’s why Obamacare needing to make signing up mandatory; it’s mathematically guaranteed to fail otherwise.

    The old HIPAA rules addressed that by guaranteeing coverage *if you were covered sufficiently recently*. If you change or lose your job, but have been paying for insurance like a responsible adult all along, you would not suffer by having to change to a different carrier.

    Is nobody in DC trying to walk the middle ground between all and nothing?

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      rlritt

      That's not true. Prior to the ACA, I knew someone who had to postpone cancer surgery several months because her employer was changing carriers and the new insurance wouldn't cover her for any cancer treatment, if she was treated previously under her former plan.

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      1. Doctor Mist

        The accommodation under HIPAA was not perfect. That doesn’t change the fact that for the system to work, people *have* to be insured before they need it. You can either require them to be insured, with all the mighty force of law behind that requirement, or you can allow them to make that choice themselves — maybe they think they have more urgent priorities than health insurance — and live with the consequences of that choice.

        If you give them that choice, you absolutely can and should make it as easy as possible to stick with that choice, including making sure that there are no holes in the creditable coverage rules. As I said, an adult who has not tried to get a free ride should not suffer when circumstances force them to change insurers.

        If you give them that choice, the whole thing falls apart if later when they regret their choice, you say, “Don’t worry, honey, we will pretend you made the right choice all along,” and give them the same care they’d have had if they had chosen right. It’s not ethics, it’s just sums.

        My own preference is to give them the choice and treat them like grown-ups. Not all will act like grown-ups, but then you know which ones to treat like children.

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          rlritt

          An employee has no power to decide what health insurance company their employer decides to go with. I worked for a company who changed their provider and everyone had to switch. Its not a frivolous decision on the employees part. Same with changing jobs. A new employer will provide different insurance. Before the ACA I knew people who couldn't change jobs because they had chronic illness and would lose insurance coverage if they changed insurance.

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            Carl Tuesday

            this is another good reason any healthcare policy proposal that doesn't talk about finding a way to decouple health insurance from employment are decoupled from good sense and reason.

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          2. Doctor Mist

            Exactly. That’s the kind of situation the HIPAA rules were supposed to address, but didn’t quite get right. But it could be *made* right without going whole hog into single payer, and without treating adults like children.

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      Pat Riot

      So somebody isn't a responsible adult and they don't pay for insurance and they show up dying at the hospital. Then what?

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      1. Doctor Mist

        Oh, good, I have tickled the so-called Pat Riot.

        You know the answer to that. They must rely on charity.

        Ad misericordiam rhetoric is always striking, and may well inspire charitable donations, but it does not alter the logic. If they are not being responsible before they are sick, they are not in a position to demand to be treated as responsible after they are sick.

        There are only two choices for a functioning system. You can require everybody to be in it, or you can wash your hands of those who choose not to and later regret it. Both have drawbacks, but whining about it does not change it.

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          Pat Riot

          Okay John Galt, good luck convincing the 90% of Americans who disagree with you and have for the last 80 years.

          Here on planet Earth we are stuck paying for irresponsible people, and will continue to be forever. The only live question is how we can do it in the most efficient and equitable way possible (and by "equitable" I would include, for instance, better treatment for responsible / rich people, but we have a floor now and we'll have a floor forever and it's not cheap to maintain even if we do it more efficiently than we are now).

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          1. Doctor Mist

            Thanks for your good wishes! :-)

            If it’s really 90% you should have had no trouble maintaining support for the individual mandate. You could not.

            Listen, you should really take my observations as ammunition for your side. The system mathematically *cannot* survive on its own without either universal buy-in or people paying the price of refusing. Anything else and adverse selection will kill it. But actuarial seriousness seems to be in short supply.

            I will reluctantly agree that in this day and age the most likely source of the charity I referred to is the government. I don’t have to like that to see that it is so. But it’ll have to be provided like charity, with everything “as available” and with the understanding that you can count on nothing at all. Anything more is unsustainable. The most good-hearted intentions in the world don’t invalidate the math.

            A system that can be as thoroughly gamed as ours can is no system at all, but a castle in the air.

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    3. Scott N.

      Oh yeah, I forgot about that one. It still doesn't cover everyone but it covers a lot of the gaps.

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      1. Doctor Mist

        And arguably it should *not* cover everyone, for the same mathematical/incentive reasons that Obamacare should not have.

        I’d even be on board with a once-in-a-century jubilee — sign up this year and you get guaranteed coverage; thereafter only if you had continuous creditable coverage. (Of course we know that exceptions granted once will be repeated forever; cf. immigration.)

        But my question is why this is not even part of the conversation? It didn’t even come up in the article.

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          Pat Riot

          If it doesn't cover everybody, something else we taxpayers pay for will (and does). Better to do this efficiently rather than inefficiently.

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    Dante Longfellow

    "forbidding insurance companies to deny coverage to people with pre-existing conditions"

    If it covers pre-existing conditions, it isn't insurance. This is the problem.

    The ACA made it illegal for companies to sell health insurance. While pre-paid healthcare plans should be available to cover pre-existing conditions, far more people--especially young people--would benefit from simply being able to purchase health insurance.

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    1. Mary Stine

      Well that is a problem, since in my experience, nearly anything can be classified as a "pre-exiting condition". Right now over 45% of Americans are obese, something that used to be considered a pre-existing condition. If you add in mitral valve prolapse, scoliosis, and flat feet, other typical pre-existing conditions that are highly common, you might get up to 75%!
      Since pre-paid healthcare plans aren't really an available option, it seems to me that the insurance industry needs to rebrand itself and and sell Illness Mediation Insurance.
      While there may still be a lot of young people who are "healthy", there are an alarming number with diabetes, asthma, obesity and other issues that, once diagnosed would throw them out of the "normal health" insurance.

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    Eston

    What a hot mess. I have 2 thoughts on this post:

    1. Does Trump (and do the Trumpists — who I can no longer call Republicans) really want to do anything substantive? He/they have no plan, other than to “repeal and replace”. Sounds like NAFTA “Redo” 2.0, meaning replace with something almost exactly the same, but change the name to something less pithy and perhaps “Trump” branded. Would this even be a fight now if the “Obamacare” tag hadn’t stuck? Sure, there may have been a few tweaks to make (good or bad, as not every tweak will be an improvement), but was healthcare really going to end? No, this is much ado about nothing much. Or at least not the right things.

    2. In my view the whole Obamacare debate started and continues from a foundation of sand, because there’s never been a fundamental society-wide debate on the policy objectives that the society wants regarding health, and the relation of health-care spending to the overall economy. The discussion concerns soundbites about everyone getting “the best care possible,” and of course it should be “affordable,” but what does that mean? Should each person get all the healthcare they need, or want, or can find some doctor to recommend, regardless of cost, ability to pay, or impacts on insurance rates for everyone? How can that possibly ever work on a long-term consistent basis? If supply and demand (pre-supposing some link between demand and payment) don’t do their magic, what’s the upper limit on the portion of the economy that will be taken over by “health care”? I know, “death panels,” but what other economic activity proceeds without any price check — even defense has limits. While protecting the ability of people with pre-existing conditions to buy health insurance at the same price as everyone else sounds good and is very popular (for obvious reasons), isn’t it also obvious that the health insurance companies have to raise rates offered to everyone in case an unexpected number of high demand/pre-existing condition consumers choose their policies? Isn’t there a balance somewhere between some limits on demand, and some impact on rates? Specifically, the “individual mandate” to have insurance is tied to the right to receive health care when needed, right? Can it possibly make sense that a person would continue to have a “right” to health care as and when needed even if that person has made the choice not to be able to pay for it by buying insurance? I never really hear about the people that want the ability to die of a disease without any treatment they can’t pay for with cash at the time because they prefer their right to not be “forced” into buying insurance (and thereby hedging their risk). The “commons” problem again.

    I don’t expect there is a single right answer to any of these issues, just as there isn’t a single right answer to any complex policy subject, but there could be a rational debate and a consensus set of coherent policy positions developed over time, probably one that requires periodic updates as experience continues to accrue. That debate seems essential to me before any progress can be made on the specific proposals to choose and implement. In the meantime, it seems the ACA is an adequate holding position, however unsustainable in the long run.

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    1. Joe1776

      Of course people will just buy insurance after they get a long term diagnosis when they can't be denied based on pre existing. And of course that will increase rates. At first the coverage on the marketplace was insanely expensive and the deductibles where insanely high, compared to employer plans. This is what I expected.

      But lately the rates seem to have dropped and become more reasonable. I do not know what changed. I do not know if it was something Trump did or something Obama did but just took a while to take effect. But the market place now has plans that seem comparable to employer plans and sometimes better. I can't explain it.

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        David Atkinson

        "Of course people will just buy insurance after they get a long term diagnosis when they can't be denied based on pre existing." If they get their diagnosis during the Open Enrollment Period - about a 45 day window - then you are correct, but if not, and they don't qualify for Special Enrollment Period, then they are out of luck and will be financially liable for their medical expenses. When the next Open Enrollment Period comes around, it won't pick up the tab for their expenses incurred while uninsured.

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      Pat Riot

      The answer to #1 is no: since the last half of Trump's term, the Republican party has *completely* given up on substantive policy of any kind. Trump has figured out that the only thing that matters to the GOP base is owning the libs and the stock market. Everything else is a waste of time for them.

      If Trump and the Republicans lose in November, the country can start the conversation again. If not, it's still a waste of time.

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    3. tla

      Politicians want to promise the sky and the moon, but health care is really hard and any reasonable solution can’t be everything for all people. It was clear when people got some hung up with “death panels” neither side was willing to talk about difficult trade offs. Democrats have tended to shrug off trade offs and the Republicans used to the be the sensible ones. No longer.

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    4. Mary Stine

      This is a very thoughtful take on what is indeed a hot, complex mess. Perhaps CNN could take this on as a series of town halls and invite doctors, nurses, nutritionists, and patients as well as policy makers to discuss what truly effective and reasonable health care would look like and what individual responsibility would look like.
      There needs to be real discussion on how we can have everyone begin life healthy, stay healthy through responsible good habits and help people with chronic diseases.
      There needs to be space and time carved out to honestly assess how much of our worse health crisis are affected by polluted air (asthma), polluted water and soil (neurodegenerative diseases like Parkinsons and Alzheimers and autism) and climate change.

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      1. dan

        I mean, this really doesn't have to be a hot mess though. Congress, tomorrow, could raise the individual mandate to a single cent and it would render the entire pending legal case against the law moot. But we're in reality and that will never happen.

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    Victor Clairmont

    Yeah so Obamacare will be fine, the supremes are not getting rid of it.

    Thanks for the article!

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      Idontdocute

      Then again, it was suppose to have been thrown out when it first went to federal court and here we are.

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  7. Bradley Potts

    I couldn't tell you if he is purposefully lying or just isn't involved enough to know what his justice department is doing.

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    1. tla

      I think he just doesn’t really understand or care. It astounds me how many people don’t see the needed link between the individual mandate and covering preexisiting conditions. Can’t really have one without the other Lets call it a tax and be done with it.

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