Trump is not to be trusted on pre- ex­ist­ing con­di­tions

Pittsburgh Post-Gazette - - Business - An ed­i­to­rial from Bloomberg Opin­ion

Pres­i­dent Don­ald Trump keeps on say­ing he’ll pro­tect peo­ple with pre­ex­ist­ing health con­di­tions even if he suc­ceeds in killing the Af­ford­able Care Act — and, oddly enough, quite a few peo­ple ap­pear to be­lieve him. Yet he has no plan for an al­ter­na­tive to the ACA, and he hasn’t said how he means to keep his promise to pro­tect those at risk.

Safe­guard­ing peo­ple with pre­ex­ist­ing con­di­tions de­mands more than vague pledges. It re­quires laws that both reg­u­late and sup­port the health in­sur­ance sys­tem — just as the ACA has done for sev­eral years. It also in­volves an in­escapable trade- off, be­cause pro­tect­ing the most vul­ner­a­ble means higher costs. The pres­i­dent re­fuses to ad­dress the is­sue se­ri­ously. As on many other mat­ters, he is not to be trusted.

Mr. Trump rec­og­nizes that vot­ers care about the ques­tion, and he talks and tweets about it con­stantly — in­clud­ing re­cently from his sickbed. At the first pres­i­den­tial de­bate, he pro­claimed, “We guar­an­tee pre- ex­ist­ing con­di­tions” — pre­sum­ably mean­ing that his gov­ern­ment will make sure that peo­ple who have chronic health prob­lems are never de­nied health in­sur­ance. He’s gone so far as to is­sue an ex­ec­u­tive or­der declar­ing his “stead­fast com­mit­ment to al­ways pro­tect­ing in­di­vid­u­als with pre- ex­ist­ing con­di­tions and en­sur­ing they have ac­cess to the high- qual­ity health care they de­serve.”

But he won’t say how. Be­fore the ACA was passed, in­sur­ers sell­ing in­di­vid­ual and fam­ily poli­cies were al­lowed to turn away cus­tomers with cancer, heart disease, di­a­betes, asthma and other pre- ex­ist­ing con­di­tions — or to charge them higher pre­mi­ums. ( An es­ti­mated 54 mil­lion nonelderly Amer­i­cans have such health con­di­tions.)

Be­gin­ning in 2014, the ACA banned such prac­tices in the in­di­vid­ual in­sur­ance mar­ket and, at the same time, capped pol­i­cy­hold­ers’ an­nual out- of- pocket ex­penses, for­bade life­time dol­lar lim­its on cov­er­age, and re­quired all poli­cies to cover 10 es­sen­tial health ben­e­fits ( in­clud­ing emer­gency ser­vices, preg­nancy and new­born care, pre­ven­tive care, and men­tal health care). In ad­di­tion, the ACA pro­vided sub­si­dies to peo­ple and fam­i­lies to help pay for their poli­cies. Col­lec­tively, these pro­vi­sions en­sure that peo­ple with pre- ex­ist­ing con­di­tions can af­ford de­cent health in­sur­ance.

They also raise costs for in­sur­ers. Peo­ple with health prob­lems have higher med­i­cal ex­penses. Since the ACA stopped in­sur­ers from charg­ing sick peo­ple more, pre­mi­ums gen­er­ally have risen. Ev­ery­one pays more so that no one goes with­out. This is how in­sur­ance pools rou­tinely op­er­ate.

Repub­li­cans, in­clud­ing Mr. Trump, have never come to terms with this trade- off in the in­di­vid­ual in­sur­ance mar­ket. They cite higher pre­mi­ums as a main rea­son to over­turn the ACA, and they have pur­sued strate­gies that would lower pre­mi­ums for the healthy with­out pro­tect­ing the sick. Repub­li­cans have pro­posed al­low­ing states to waive the rule against charg­ing more to peo­ple with pre- ex­ist­ing con­di­tions or the re­quire­ment to cover 10 es­sen­tial ben­e­fits. They’ve talked about al­low­ing in­sur­ers to limit life­time or an­nual cov­er­age, not cover es­sen­tial health ben­e­fits or not sell poli­cies to peo­ple with pre- ex­ist­ing con­di­tions.

They have also ar­gued for so­called high- risk pools, funded by gov­ern­ment, which would de­fray the high costs of care for peo­ple with pre- ex­ist­ing con­di­tions. The­o­ret­i­cally, these could lower costs for in­sur­ance buy­ers, but only if they were gen­er­ously funded. The states that have tried them up to now have gen­er­ally failed to pro­vide enough money.

The Trump ad­min­is­tra­tion has al­ready eroded pro­tec­tions for peo­ple with pre- ex­ist­ing con­di­tions by length­en­ing to three years the du­ra­tion of “short term” in­sur­ance plans, which don’t have to fol­low the ACA rules. More omi­nously, it has joined a law­suit filed by Texas and other Repub­li­can­lean­ing states that could kill the ACA al­to­gether. That’s why Se­nate Democrats have been right to raise the is­sue in hear­ings this week on the Supreme Court nom­i­na­tion of Amy Coney Bar­rett. If con­firmed, she might soon be hear­ing ar­gu­ments on the ACA chal­lenge.

Re­gard­less of Judge Bar­rett’s nom­i­na­tion, the is­sue is cru­cial for Amer­i­cans cast­ing bal­lots in the elec­tion next month. The ques­tion is whether they want a gov­ern­ment that keeps say­ing it will pro­tect peo­ple with pre­ex­ist­ing con­di­tions, or one that ac­tu­ally in­tends to do it.

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