It’s not hyperbole to say that quality health care for millions of Americans with preexisting conditions hangs in the balance on Nov. 3. That should matter not just to them but to their relatives and families as well.
If Democratic nominee Joe Biden wins the presidency and Democrats retake the Senate, the Affordable Care Act, along with its protections for those with preexisting conditions, stays. Should the US Supreme Court strike it down, as President Trump advocates, a President Biden would certainly push to remedy and reinstate the law. What’s more, Biden would try to enhance the statute by adding a Medicare-like public option and increasing tax subsidies to make coverage purchased on the health-insurance exchanges more affordable.
Not Trump. He has attempted to repeal Obamacare before — and if reelected, he would certainly try again. If the high court invalidated the law, he wouldn’t save it.
Trump says he would replace the ACA with health care that is much cheaper and much better. But he has been promising that since his 2016 campaign and has never unveiled a proposal that would accomplish those twin goals.
Trump has also repeatedly pledged that he and the Republican Party will protect coverage for those with preexisting conditions if the ACA is struck down. But there’s no such plan there, either. In the absence of one, the president has signed an executive order declaring it administration policy to do so. But absent an actual proposal — one that would be passed legislatively — that executive order qualifies as nothing beyond a political blandishment.
Those at most immediate risk would be the 12.5 million Americans who buy ACA-compliant plans on the individual market. If they have preexisting conditions, insurers could once again charge them much higher premiums or exclude from coverage the cost of treatment for those conditions. But some protections, like a prohibition on annual and lifetime caps on care, also help those who receive their insurance through their employers. Further, without the ACA, job-changers could face waiting periods for coverage of preexisting conditions at their new place of employment. According to the Kaiser Family Foundation, about 25 percent of adults too young for Medicare, or about 54 million people, have preexisting health conditions today that would probably have made them uninsurable in the individual markets before the ACA was passed.
Empty promises notwithstanding, there is no easy solution to replace the existing policy that doesn’t end up having a considerable cost. Patients who have preexisting conditions are expensive to treat.
“These are in many cases sick people with significant health care expenses, so the money to cover them has to come from somewhere,” says Larry Levitt, executive vice president for health policy at the Kaiser Family Foundation. “It can come from other people who are insured, from the government, or some combination of the two.”
Under the ACA, we have spread their costs over the larger pool of insured people. Doing so raises premium costs for everyone who carries insurance, be it employer-provided or individually purchased, but allows those with preexisting conditions to have access to insurance at an affordable price.
Alternatively, you can remove those cases and the costs associated with them from private insurance pools and pay for them with public dollars. That could be done either directly, the way it is with people who are on Medicare or Medicaid, or through subsidized high-risk pools or groups.
That approach would lower the costs of insurance premiums for those without preexisting health problems. But those high-risk pools would require significant tax-dollar subsidies if the insurance is to be affordable for those with chronic health problems.
So it’s really a matter of which source of subsidy — the private premium pocket or the tax-dollar pocket — is tapped to lower insurance costs for that population.
When Vice President Pence was queried recently about the administration’s “plan” for preexisting conditions, he, like Trump, offered nothing by way of specifics. However, he did mention that the GOP’s 2017 effort to repeal the ACA had included some money to incentivize states to establish high-risk pools.
“It used what is called high-risk pools, where people with preexisting conditions could get subsidized coverage on the state level,” he said.
Problem: There was widespread agreement that the GOP grants for state high-risk pools were underfunded, the more so since states could have used that money for a number of different purposes.
Back in the days before the ACA, 35 states had such pools. They did not work well. Premiums were much higher than for those without previous health problems. Even then, most such pools had 6-to-12-month coverage exclusions for preexisting conditions. Further, 33 of the pools had lifetime caps on coverage costs, typically in the $1 million to $2 million range.
“For the most part, the outcomes for consumers were unacceptable, which was a critical issue in the passage of the Affordable Care Act,” says Phil Johnston, former regional administrator for the US Department of Health and Human Services in the Clinton administration.
With policy as complicated as health care, the devil is always in the details. And when there are no details, but just an election-year promise? Voters, beware. It’s not a policy you are being offered, but rather a pig in a poke.
Editorials represent the views of the Boston Globe Editorial Board. Follow us on Twitter at @GlobeOpinion.