New GOP health care reform proposal is a puzzle. Where do people with pre-existing conditions fit in?

House Majority Leader Kevin McCarthy of California, left, and Speaker Paul Ryan of Wisconsin may try again this week to pass the Republicans’ plan to reform the Affordable Care Act.
House Majority Leader Kevin McCarthy of California, left, and Speaker Paul Ryan of Wisconsin may try again this week to pass the Republicans’ plan to reform the Affordable Care Act. The Associated Press

After their last few attempts went up in flames in the face of massive public opposition, President Donald Trump and House Republicans are once again trying to destroy the Affordable Care Act. They wanted to give Trump his first major victory before the 100th day of his presidency, but they couldn’t find enough votes. They will try again this week.

Oddly, the new proposal eliminates one of the most popular parts of the ACA – the requirement that insurers offer affordable, adequate coverage to patients with pre-existing conditions. Instead, the proposal allows insurance companies to charge those patients exorbitant prices for bare-bones plans.

The latest proposal is a puzzle. Its effects will be so unpopular that it’s not clear why Republicans would support it. About half of Americans report that someone in their household has a pre-existing condition and, of course, any of us could get one at any moment. So not only will the proposal reduce the health security of all Americans, but it will likely anger the half of Americans who are immediately harmed by it.

Before the ACA, a central business strategy of insurance companies was to avoid “sick” patients who were more likely to use costly medical services. Insurers excluded people with pre-existing conditions by charging them higher prices or denying them coverage entirely. And insurers often defined pre-existing conditions quite broadly. Insurers could exclude people with common allergies and acne, expectant mothers and fathers, and people who had received mental health treatment. Some insurers even excluded police officers and firefighters because of their risks on the job.

The Affordable Care Act changed all of this. It required insurers to accept everyone and prohibited them from charging higher prices for people with pre-existing conditions. It also required that insurance plans include a set of 10 essential health benefits.

The Republican proposal allows states to essentially eliminate these rules – insurance companies could once again discriminate against people with pre-existing conditions.

Republicans claim that their new proposal maintains coverage for pre-existing conditions, but that is just not true. Yes, insurers will still be required to sell insurance to anyone who can afford it, but they can charge any price and severely limit the treatments that it covers. If you, me or one of our friends or family members ends up with cancer and tries to buy insurance on our own, no insurer can outright refuse us. But they can still keep us away by charging us more than we can afford or by offering us a plan that doesn’t cover the things we need, like chemotherapy.

Republicans also claim that their proposal will merely give states the “option” of reducing protections for people with pre-existing conditions, but states will actually be forced to do so by other parts of the bill. Because the bill allows (currently) healthy people to opt out of insurance, the vast majority of states, facing rising premiums, will have no choice. Before the ACA, 43 states allowed insurers to discriminate against people with pre-existing conditions.

The Republican plan is a far cry from what Trump promised Americans – affordable, high-quality coverage for all. If it becomes law, it will be a medical and financial disaster. People with serious conditions, but no insurance coverage, will live shorter and sicker lives, face financial distress and often be forced into bankruptcy.

The plan will also be a political disaster for Republicans because it will hurt so many Americans. And some of us, including many people who voted Republican last November, are likely to be upset about that.

Drew Halfmann is an associate professor of sociology at the University of California, Davis, where he writes and teaches about health policy. He is a member of the Scholars Strategy Network and can be contacted at