U.S. healthcare has a new third rail

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It’s the guarantee – first provided to all Americans by the Affordable Care Act – that people with pre-existing health conditions will have access to affordable private health insurance.

The coverage of 54 million Americans with health problems would be at risk if the protections currently contained in the Affordable Care Act (ACA) were declared unconstitutional in a pending court case, or if opponents of the law succeeded in redoubling their effectiveness. ‘efforts to repeal it.

The “pre-ex” question – how to ensure that people with pre-existing health conditions can get affordable insurance coverage – resonates at the kitchen table.

Americans overwhelmingly want to protect sick family members, friends and neighbors. Eighty-two percent support guaranteed coverage, regardless of pre-existing conditions and even if it raises premiums.

And the issue featured prominently in Democrats’ resurgence during the 2018 election cycle following a year-long effort by Republicans in Congress to “repeal and replace” the ACA.

Progressives have little exposure on the pre-ex issue. They are in favor of maintaining or expanding ACA coverage, or even beyond to adopt some version of universal public insurance, which would cover everyone, no questions asked.

The Conservatives face a more difficult challenge. They typically favor private sector solutions to health problems, but private health insurers on their own have historically failed to cover many of the sickest Americans. This leaves the Conservatives between a rock and a hard place in any attempt to balance limited government principles with the realities of the private health insurance market.

People with pre-existing conditions are, by definition, generally sicker, so they are riskier and often less profitable to insure, even though private plans charge high premiums that are unaffordable for everyone except the wealthiest. This was the dilemma many sick Americans faced without employer-sponsored, Medicare, or Medicaid coverage before the ACA.

One solution would be to ensure that private insurers enroll enough healthy people so that the earnings of these low-cost customers offset the losses of the pre-ex population.

But that’s easier said than done, because many healthy people know they are unlikely to need care. pre-existing problems.

This is where the shoe pinches for the Conservatives – to address this private market failure, the government must get involved. First, it must require private insurers to accept individuals regardless of their state of health. Second, it must demand that plans charge affordable premiums that are unrelated to clients’ health. This is called community scoring.

Third, the government must ensure that private insurers have a plentiful supply of healthy customers who pay for generous coverage – a balanced risk pool in insurance parlance. The latter condition requires the government to subsidize the purchase of private insurance for people who cannot afford it (the poor, near-poor or increasingly the middle class) or to require the purchase of private insurance. ‘full private insurance, or both.

These are the strategies that the ACA has put in place. And its expansions of government authority are precisely the reason the Conservatives oppose ACA or something like that.

As an alternative, some conservatives are proposing to let states decide what to do on the pre-ex issue. This approach would allow federal lawmakers to stay true to conservative principles, while, in principle, prioritizing coverage for pre-existing conditions.

But that leaves supporters exposed to the accusation that they are only passing the buck, especially since conservatively-led states may also be unwilling or unable to take the steps necessary to make the markets the same. viable private insurance for people with pre-existing health problems.

Faced with similar dilemmas in the past, the Conservatives have found new solutions. Indeed, the very idea of ​​an insurance mandate arose from conservatives searching for market-based alternatives to Democratic proposals for government-sponsored universal health insurance.

Much remains to be seen as to whether the ACA will survive in court and what the 2020 candidates might come up with to resolve the pre-ex issue if the ACA is overturned by the Fifth Circuit Court of Appeals. But there is no doubt that protecting people with pre-existing conditions has become a deep and widely shared American value.

Voters should demand that candidates approach the pre-ex issue bluntly and should carefully consider promises – whether right-wing or left-wing – that claim to solve the problem.

David Blumenthal, MD, MPP, is Chairman of the Commonwealth Fund, a national philanthropic organization engaged in independent research on health and social policy issues.


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