JD Vance reopens the pre-existing condition debates

In order to cover people with expensive pre-existing conditions, the ACA imposed strict new regulations on insurers that many conservatives have criticized: It required them to offer a minimum suite of “essential benefits” in all plans, it limited how much they could charge based on age (with older adults paying no more than three times as much as younger ones), and it required them to take on all customers regardless of their past or present health status.

In his “Meet The Press” appearance, Vance said Trump would pursue a “deregulatory agenda” around the ACA in order to offer a wider variety of plans, and appeared to reference several of these provisions in the interview.

He said that “a young American doesn’t have the same health care needs as a 65-year-old American” and that “a 65-year-old American in good health has much different health care needs than a 65-year-old American with a chronic condition.” This could be taken as a reference to the rules that require insurers to offer customers similar plans, and possibly to the law’s caps on age-related premiums, although because people over 65 are eligible for Medicare it makes the exact point a little unclear. He also criticized the law for putting people into “the same risk pools” with a “one-size-fits-all approach” — a seeming reference to prior Republican proposals to offer insurance to people with expensive conditions in separate “high risk pools” rather than require insurers to cover everyone together under similar plans.

The “American Health Care Act” that passed the GOP-led House in 2017 put forward several proposed solutions based on these conservative criticisms, including offering states a waiver that would allow insurers to sell plans that adjusted premiums based on pre-existing conditions in some circumstances and that did not include minimum essential benefits. A Congressional Budget Office analysis of the bill found that this tiered system of insurance would create a situation for people with expensive conditions in which “premiums would be so high in some areas that the plans would have no enrollment” as younger and healthier people opted for cheaper, health-dependent plans and older and sicker people were funneled toward the pricier, more robust ones. The bill also included some money to help subsidize the latter group’s coverage, but the CBO concluded it “would not be sufficient to substantially reduce the large increases in premiums for high-cost enrollees.”

“You can’t really say people with pre-existing conditions are protected if they are in a separate insurance risk pool and can be charged exorbitant premiums,” Larry Levitt, executive vice president for health policy at the nonpartisan research group KFF, tweeted after Vance’s interview.

The state waiver provision was later ruled out by the Senate parliamentarian on technical grounds, who concluded it violated procedural rules around legislation passed by reconciliation, and the House bill never became law.

Ultimately, Trump was only able to make changes at the edges of the ACA in Congress, but his administration did pursue a related approach at the executive level by authorizing the sale of insurance plans that could be purchased outside the law’s individual marketplace and not follow its rules.

A spokesman for the Trump campaign, Brian Hughes, declined to provide specific answers to questions about whether the candidate favored moving people with pre-existing conditions into a separate risk pool and whether he would favor changing the current age bands on premiums. Hughes did tell Semafor that the president and Vance were broadly aligned on health care policy.

“Senator Vance and President Trump share the underlying principles of using more choice in the marketplace and efficiency as tools for better, more affordable health care,” he said.

“There should be no doubt about Donald Trump’s commitment to end the Affordable Care Act — he and House Republicans tried doing it over 60 times,” Harris-Walz spokesman Joseph Costello said in a statement on Wednesday night. “Now, one of the ‘concepts’ he’s bringing back is his plan to rip away protections for pre-existing conditions, throw millions off their health care, and drive up costs for millions of Americans with pre-existing conditions. If Trump takes power, he promises to put health care for working families on the chopping block, just so he can give tax handouts to his billionaire donors.”

Vance’s comments don’t amount to a clear proposal, but they do illustrate one reason Trump and other Republicans have been reluctant to get into the weeds on health care since 2017: The entire policy debate is filled with difficult tradeoffs. Getting rid of some regulations on insurance could make insurance cheaper for some younger and healthier voters, for example, but raise prices for older and sicker ones. In theory, it’s also possible to insure people with pre-existing conditions through different means, like subsidized high risk pools, but it would take tremendous amounts of federal funding to cover their care — which could disappoint conservatives looking to reduce spending in any new health care plan. There’s no cheap and easy shortcut to covering the same number of people the ACA does with the same level of coverage and without some disruption to the current system.

In a campaign appearance on Wednesday in North Carolina, Vance again discussed major changes to the ACA that could effectively end current protections for pre-existing conditions by moving chronically ill patients into separate categories of insurance.

“We’re going to actually implement some regulatory reform in the health care system that allows people to choose a healthcare plan that works for them,” Vance said. “If you only go to the doctor once a year, you’re going to need a different health care plan than somebody who goes to the doctor fourteen times a year because they’ve got chronic pain or they’ve got some other chronic condition. That’s the biggest and most important thing that we have to change. Now, what that will also do is allow people with similar health situations to be in the same risk pools, so that makes our health care system work better, makes it work better for the people with chronic issues, it also makes it work better for everybody else.”