Everybody knew that the Pledge for America would include a vow to "repeal and replace" the Affordable Care Act. But in the last day or so, an intriguing rumor began to circulate. Supposedly the Republicans would guarantee that people with pre-existing medical conditions could buy good health insurance on their own.
You can imagine why Republicans would want to do this. Americans may have mixed feelings about both health care and health care reform. But, with very few exceptions, they think it's wrong to deny decent insurance to somebody just because that person struggles with asthma or beat cancer a few years ago.
The Affordable Care Act would solve that problem in a straightforward, sensible way. It would explicitly prohibit private insurers from denying coverage or charging higher premiums to people with pre-existing conditions. It would also force insurers to cover a basic set of benefits while limiting out-of-pocket expenditures. Polls have consistently shown these promises to be among the law's most popular features. That's one reason you almost always hear President Obama mention talk about them in his speeches.
The problem for Republicans is that these provisions are all forms of regulation. Republicans hate regulations. What's more, the Affordable Care Act requires that all people get insurance--i.e, the law includes an "individual mandate"--in order to make sure people don't game the system by remaining uninsured until they get sick. Republicans oppose that, too, although once upon a time plenty of them supported the idea.
So how would Republicans solve this dilemma? How would they get insurance to people with pre-existing conditions without all of the Affordable Care Act's regulations? Simple. They don't really do it.
Here's the key provision in the Pledge:
Ensure Access For Patients With Pre-Existing Conditions: Health care should be accessible for all, regardless of pre-existing conditions or past illnesses. We will expand state high-risk pools, reinsurance programs and reduce the cost of coverage. We will make it illegal for an insurance company to deny coverage to someone with prior coverage on the basis of a pre-existing condition, eliminate annual and lifetime spending caps, and prevent insurers from dropping your coverage just because you get sick. We will incentivize states to develop innovative programs that lower premiums and reduce the number of uninsured Americans.
It sounds great, but note what is said--and what isn't--in that bolded sentence.
First, the pledge prohibits denying coverage only to people who have "prior coverage." The problem for many people is that they've had coverage and lost it. Maybe they became unemployed. Or maybe they could no longer keep up with the premiums. Or maybe they never had coverage in the first place, because insurers wouldn't touch them. Whatever. Even if the Republicans successfully enacted the Pledge, insurers could still deny these people coverage, just as they do today.
Second--and this is really the more important part--the pledge says nothing about benefits or premiums. That's huge. Under the Republican scheme, an insurer might not be able to deny coverage to somebody with a pre-existing condition. But they could charge sky-high premiums. Or offer packages with gaping coverage holes.
So if you have diabetes, an insurer could sell you a policy that doesn't cover complications from the disease. If you survived cancer, insurers could refuse to cover recurrences. And even if the policy did cover these things, there'd be nothing to prevent insurers from imposing huge cost-sharing--or doubling or tripling your premiums. Again, that's pretty close to the situation today.
Of course, there's more to the Republican health care proposal than just this one provision. There's talk of high-risk pools and reinsurance, ideas that experts have widely panned (at least as permanent, stand-alone solutions) because they never have enough and almost always provide inferior coverage.
Overall, the Pledge provision on health care are the same mix of ideas we've seen from the Republicans before, about which I wrote last week. Here's what I said then:
It will force a lot of people to pay higher premiums. It will lavish subsidies on the private insurance industry. It will put life-and-death decisions in the hands of bureaucrats. And it will add hundreds of billions of dollars to the federal debt.
You know what? The exact same conclusion applies now.