Preexisting Conditions and Republican Plans to Replace Obamacare

This was published as a Wall Street Journal Think Tank column on December 9, 2016.

As debate about Obamacare’s future moves from people’s general, mostly partisan views of the Affordable Care Act to details and consequences of plans to repeal and replace the ACA, one of the biggest flash points is likely to be how people with pre-existing medical conditions are affected.

Across the U.S., people who have cancer, heart disease, diabetes, or other serious conditions will want to know whether they or their sick family members will be able to get and afford coverage in the future. Their partisan views about Obamacare are likely to quickly be supplanted by these more practical concerns. And a substantial number of people could be affected.

A Kaiser Family Foundation analysis to be released next week found that almost 30% of U.S. adults younger than 65 have health conditions that would have left them uninsurable in a pre-ACA world. Many more people have conditions with which they could still qualify for coverage before ACA protections took effect–but only at premiums they could not afford. Many people with conditions over which coverage could be declined before the ACA live in big red states (there are more than 4 million in Texas, for example) and in blue states (nearly 6 million in California). As the chart above shows, however, the 11 states with the largest shares of adults who have pre-existing conditions are all controlled by Republicans, and most are in the South. These states have higher rates of residents with conditions over which coverage was declined before the ACA, such as obesity and diabetes.

Still, even more Americans may feel that they have a stake in policies regarding pre-existing conditions. Kaiser’s monthly health tracking poll found in August that 53% of Americans said that they or a family member had a pre-existing condition after being read a definition of the term. Most people with pre-existing conditions are insured at any given time through employer plans or public programs such as Medicaid. Before the ACA, however, they would have been unable to get coverage again if they lost their insurance through a change in circumstances. Because so many people with a pre-existing condition have to worry about whether their circumstances might change someday, a much larger share of the public is likely to be interested in this issue than the number of people who stand to be affected immediately by policy changes.

President-elect Donald Trump has said that he wants to protect people who have pre-existing medical conditions. Details of Republican health-care plans are not yet known, but they are expected to involve establishing high-risk pools within states, among other measures. Without the plan details it is hard to say how strong protections will be.

Tens of millions of people with pre-existing medical conditions and the influential groups that represent them will be interested in details of legislative plans to change the ACA and how they might be affected. It’s sometimes said that this has become a post-factual world. But as health care moves from a campaign issue to the legislative agenda, people will want to know how changes would affect them, and details and facts will matter more again.

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