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.
| James P. Sutton | Oct 14, 2020 | 27 | 36 |
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.
There’s a reason for the disparity. President Trump’s administration has pursued policies at odds with his professed interest in protecting coverage for those with pre-existing conditions. He came into the White House in 2017 with “repeal and replace” of the ACA as a clear priority. But after multiple proposals in the House, then Senate, the final, exhausted attempt at a “skinny repeal” was voted down, with Sen. John McCain a dramatic last-minute vote against. While some protections for patients with pre-existing conditions were proposed in the 2017 negotiations, some versions of the repeal bill, especially the House’s, would have weakened them.
Subsequent challenges to Obamacare have come in the form of enforcement and regulatory changes enacted by the executive branch, as well as the court challenge mentioned above. While rules on pre-existing conditions have not been changed, changes in rules governing “short term plans” have had an indirect effect on patients with pre-existing conditions.
Short-term plans are free from the requirements that mandate insurers must cover pre-existing conditions and those who have them, and they were intended to serve as three-month stopgaps by the Obama administration. The Trump administration extended the time limit to 364 days, with the possibility of insurer-granted extensions extending it to three years. In effect, these cheaper, less regulated plans created a second market for insurance, which many Democrats warned at the time would draw customers away from the broader insurance market, and subsequently drive up premiums for those with pre-existing conditions.
But President Trump and other Republicans have insisted that the fundamental protections for those pre-existing conditions would remain untouched. Tom Miller, a health care analyst at the American Enterprise Institute, says, “If you wanted to, in a perverse way, give Trump credit, you could say that the totality of his actions have actually reinforced and extended support for the protection of the restrictions on pre-existing conditions across the board.” The administration’s effective abolition of the individual mandate in 2017 “basically took away the main source of opposition to the Affordable Care Act,” says Miller. In the 2018 elections, when Republicans were asked why they opposed the ACA, “they had a little more trouble coming up with an answer and they had to immediately say, ‘but I don’t want to get rid of [rules protecting people with] pre-existing conditions,’” Miller noted.
Of course, failed attempts at “repeal and replace” and some regulatory tinkering, along with a public commitment to protecting those with pre-existing conditions, do not make President Trump seem like a committed opponent of Obama-era protections. But his administration is nevertheless actively working to end coverage for just these people. Trump’s Justice Department has joined the 18 states opposing the ACA in California v. Texas, filing a brief that argues that the Supreme Court should strike down the entire law along with the individual mandate, including the section referred to as “guaranteed issue” which mandates coverage for people with pre-existing conditions.
The president, then, has taken entirely contradictory positions on a major issue, as he has so many other times in his tenure. He loudly and insistently proclaims his allegiance to protections for those with pre-existing conditions while Justice Department lawyers argue for overturning those very protections. And as on many other issues, those positions are held together by the promise to use his dealmaking skills to craft an even better replacement, with details to be filled in later. But in the unlikely event of the ACA’s nullification or repeal, Miller noted, Congress would most likely “grimace and they would end up passing if not exactly the same thing, something similar to it, because they lack the imagination to do something more creative.”
Photograph by Saul Loeb/AFP/Getty Images.
| 27 | 36 |
"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.
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.