The Republican health care plan is to pretend pre-existing conditions aren't real

President Obama signs the Affordable Care Act into law in 2010. Photo credit: Obama White House Archives.

The Republican party does not have a health care plan. It never did.

But they see, like anyone with a functioning brain, that Democrats are winning the debate on health care as the Affordable Care Act - often referred to as Obamacare affectionately or pejoratively, depending on whom you ask - is more popular than ever. Not only did Democrats win the largest popular vote margin in history for a midterm year in 2018, putting Nancy Pelosi back in the Speaker's seat, polls show support for the ACA surging with a prospect of its invalidation through the Supreme Court becoming real with the GOP's obsession with packing the Court before Americans can have their votes counted.

According to a Morning Consult poll, the popularity of Obamacare has surged even since earlier this year, with 62% of voters approving in September, compared to 55% approval in March. Opposition to it ticked down from 29% to 24%. Voters trust Biden on health care over Trump by a nearly identical margin, 61 to 29. Obamacare's popularity is up across the political spectrum with, for the first time, fewer than 50% of Republicans registering disapproval.

9 out of 10 voters who support the Affordable Care Act see protecting and strengthening it as a critical voting issue, and individual components of the law enjoy even broader, across-the-board support. 79% of voters, including 63% of Republicans, are unwilling to give up on Obamacare's protections for people with pre-existing conditions, something that will immediately end should Trump succeed in appointing to the Supreme Court a fifth vote to overturn the law wholesale, as his Justice Department is asking the Court to do.

These numbers spell disaster for Republicans this November. Donald Trump's so-called executive order that the White House hopes to sell as a political defense against voter anger targeting the GOP has no provision requiring insurance companies not to discriminate against people with pre-existing conditions should the Supreme Court with Justice Ginsburg's seat occupied by Amy Coney Barrett strike down the Affordable Care Act wholesale, and in fact, the president has no power to force insurance companies to do anything they are not required to do by law.

So the Republicans have come up with a new strategy. They know that no one trusts them to protect the health care of vulnerable Americans, so they have embarked on a campaign to convince us that there are simply not that many people who are vulnerable.

Donald Trump, in the midst of his disastrous, petulant, tantrum-filled debate performance, charged that there aren't actually 100 million Americans living with pre-existing conditions whose health care would be adversely affected should the Affordable Care Act be invalidated by right wing judicial activists. Since Trump's pronouncement, a steady drumbeat of radical Republicans have been echoing the same message. Texas Republican Sen. John Cornyn this morning is peddling just such a myth penned in the opinion pages of the Wall Street Journal.

At the heart of this outrageous concoction isn't actually a dispute about the number of Americans with pre-existing conditions, which is already more than 130 million and growing each day with aftereffects of COVID-19, but a contention that the Affordable Care Act didn't make a difference in the lives of that many people with pre-existing conditions.

This is, of course, a lie. Contrary to Republican claims that only about 2.5 million people with people with pre-existing conditions have directly gained health care coverage through the Affordable Care Act, the number directly insured by the marketplaces was actually pegged at a total of 12 million by the Commonwealth Fund in 2017, well over a 60% of the total number of people who gained access to coverage through the Obamacare exchanges. Of this 12 million total, the Commonwealth Fund estimated that 2.6 million people would have been denied coverage altogether before the ACA, while the other 9.4 million would have been charged higher premiums for their pre-existing conditions.

The Republicans' insistence on the 2.6 million number says all we need to know about their approach to pre-existing conditions: they do not consider anyone who has a pre-existing condition but is merely charged exorbitantly high premiums because of it rather than being fully turned down for coverage as having any problems.

This attitude also represents a fundamental misunderstanding about what protections for pre-existing conditions through the ACA actually means. The ACA does not simply mandate that insurance cannot deny coverage to people (guaranteed issue) with pre-existing conditions, it also guarantees that:

  1. People with pre-existing conditions can buy coverage at the same price as those without such a condition. Commonly referred to as 'community rating' in health policy lingo, this is the protection that actually makes coverage possible for those living with a pre-existing condition. The distinction between denying coverage to someone with a pre-existing condition and pricing them out of the market while still technically offering them a plan is one without a difference.

  2. People with pre-existing conditions are eligible for the same subsidies as anyone without one, making it actually affordable for them to purchase the insurance plans that are offered - or in states that have chosen to expand Medicaid under the ACA, offer them free insurance if they make under a certain amount.

From all indications, Republicans also plan to argue that pre-existing conditions are covered for anyone who has an employer-sponsored plan, as group plans, as opposed to individual plans, have been required to cover pre-existing conditions since 1996. This, too, is a severely weak argument that highlights yet another key protection for people with pre-existing conditions under Obamacare: they can leave their jobs without fear of being deprived of health care because no one in the individual market would insure them for a reasonable premium.

This is the protection that the vast majority of people with pre-existing conditions, who are employed, count on, and will not be willing to part with.

Not to mention, a tearing up of the ACA would devastate employer-based coverage itself for millions of young adults under the age of 26, who only have coverage through their parents' employer-based plans because of Obamacare. The ACA cut the young adult uninsurance rate by half. It is estimated that one in four young adults have a pre-existing condition.

The judicial repeal of Obamacare would send the system back to a day where employers had extraordinary leverage over not only employees but over the families of employees with pre-existing health conditions, a system that would also ignore the massive shifts in the employment market in the past quarter century. People switch jobs far more often now than they used to, and more people are making a living in the gig economy.

Pre-existing conditions are not a myth. Protections for pre-existing conditions go well beyond those who directly purchase a plan in the individual marketplace. In fact, the protections against pre-existing condition discrimination is in many ways the underpinning of not just health care coverage but of the economy itself.

Make no mistake, the Republicans do not have a plan to protect more than 100 million people with pre-existing conditions should ACA no longer exist, because they don't plan on protecting them. There is only one cure for this national ailment.

Vote them out.