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Pre-Existing Conditions: Campaign Ads vs. Voting Records
By Richard G. Thomas

Republicans in Washington, from the Tea Party faction in Congress to former Speaker Paul Ryan, Senate Majority Leader Mitch McConnell and President Donald Trump, have spent 10 years attempting to repeal the Affordable Care Act (ACA).

But during this year's election campaigns -- at the same time the Trump administration is urging the Supreme Court to declare "Obamacare" unconstitutional -- the president and GOP congressional candidates are telling voters they support a key portion of the law that ensures individuals with medical conditions can get health insurance. The provision, like some other parts of the law, has proven highly popular, particularly now that large numbers of previously healthy Covid-19 survivors find themselves in that category.

In television ads aired by Republican senators facing voters Nov. 3, Martha McSally of Arizona promises to "always protect those with pre-existing conditions," David Perdue of Georgia says "health insurance should always cover pre-existing conditions," and Steve Daines of Montana "will protect Montanans with pre-existing conditions," his commercial vows.

It would amount to campaign malpractice for a candidate of either party to say otherwise amid the country's worst pandemic in 100 years and a struggling economy that has cost millions of workers their medical insurance along with their jobs.

Claims in Ads Could Backfire

But for Republican incumbents on this year's ballot, such claims could easily backfire given their participation in the party's lockstep opposition to the health law in scores of congressional votes. Trump and congressional Republicans nearly made good on their pledge to repeal the law, but the effort was narrowly defeated in the Senate in 2017. An earlier repeal bid failed when President Barack Obama vetoed Republican legislation in 2016.

As recently as July 30, House Republicans voted almost without exception to back the lawsuit filed by GOP attorneys general from several states, now before the Supreme Court, that would overturn the health law, including the pre-existing conditions safeguards now being extolled in campaign ads.

In the Senate, McConnell has recently steered clear of record votes that would compel GOP senators to take a stand on the health law. But Democrats forced an Oct. 30, 2019, vote on an order by Trump permitting states to allow the marketing of short-term, non-ACA-compliant plans that could lead to those with pre-existing conditions being priced out of affordable insurance.

McSally, Perdue and Daines voted to uphold Trump's decree, as did all other Republicans except Susan Collins of Maine, who joined Democrats in voting to repeal it. (Collins is the only GOP senator to vote consistently in support of the health law in recent years.)

Republicans "100 Percent Committed"

Sen. John Barrasso, R-Wyo., a physician, said in the October debate that "Republicans remain 100 percent committed to protecting people with pre-existing conditions," without offering details. But health organizations including the American Lung Association and the American Heart Association said the order would "jeopardize adequate, affordable coverage for people with pre-existing conditions in the individual market."

Trump, who once said "nobody knew health care could be so complicated," appears to be at war with himself on pre-existing conditions. At the same time his administration is asking the Supreme Court to eliminate the protections, he is promising to issue an executive order to preserve them.

Ryan, as the main architect of healthcare policy for congressional Republicans over nine years, was never able to present an actuarily sound way of retaining affordable pre-existing conditions safeguards while dismantling parts of the health law necessary to achieve large and diverse pools for spreading risk.

His leading proposal was to concentrate what he said were the 8 percent of persons under 65 with pre-existing conditions in state-run, federally subsidized high-risk pools. This would enable other non-seniors outside of Medicaid to form into healthier pools, and the result, Ryan told a CNN town hall in 2017, is that "you'd dramatically lower the price for the other 92 percent of Americans."

There were 17.9 million uninsured Americans with pre-existing conditions when the health law took effect in 2010, according to the Department of Health and Human Services.

State Risk Pools "Prohibitively Expensive"

Ryan called his plan "a smart way of guaranteeing coverage for people with pre-existing conditions," but the Commonwealth Fund, which specializes in healthcare research, concluded in a 2017 report it would be "prohibitively expensive."

Congressional Republicans proposed taxpayer subsidies of up $10 billion annually for pre-existing conditions coverage in state-run high-risk pools, the report said, while the actual cost to deliver affordable care would be nine times that figure. Premiums were to have covered $103.3 billion of the $194.8 billion overall cost, leaving $91.3 billion to be paid by federal and state treasuries, according to the report.

There is broad agreement among experts that from an actuarial standpoint, it is impossible to provide sustainable pre-existing conditions protections separate from other parts of the health law. Medical insurance, to be affordable, must spread risk over diverse pools of recipients in terms of age, health status and other factors, and those with pre-existing conditions need to be included in such pools to keep their premiums from skyrocketing.

As it now stands, the 2010 health law puts individuals with pre-existing conditions into pools with younger, healthier policyholders and requires plans offered in ACA marketplaces, as well as employer-provided plans, to have "community rating," which prohibits the setting of rates based on one's health status.

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Copyright 2020, Thomas Voting Reports, Inc.