Analysis: Health, money, politics -- what's in it for you (or not)?
March 1, 2020
President Donald Trump recently has been making a striking claim – insisting he has ensured that people with preexisting medical conditions continue to have health insurance coverage. In tweets, at campaign rallies and even at his recent State of the Union speech, Trump says: "I was the person who saved pre-existing conditions in your healthcare."
This comes at the very same time that his own Justice Department pushes to eliminate the Affordable Care Act (ACA) altogether, including pre-existing conditions for millions of Americans. In addition, some of the policy proposals he is supporting, if approved, would weaken coverage for Americans, especially those with pre-existing health issues, experts suggest.
Pre-existing conditions, one of the key components of the 2010 law, better known as Obamacare, was one of the driving forces that flipped the House of Representatives back to Democratic control in 2018 and is certain to be a major issue in the upcoming November presidential elections.
The ACA provides pre-existing condition coverage for some 54 million or 27 percent of people under age 65 who have pre-existing health issues. There are no exact numbers of people over 65 with pre-existing conditions. But Medicare estimates that 86 percent of people over age 55 have some kind of pre-existing condition – and there are currently 64 million people on Medicare with that number expecting to skyrocket to 79 million in 2030.
Before Obamacare, insurance companies routinely denied people coverage if you had a pre-existing condition. Statistics at the time revealed that almost 50 percent of those who sought private insurance with pre-existing conditions didn't get it, were denied coverage or charged a higher premium or had their condition excluded because of it.
The Obamacare law established consumer protections for Americans who buy their insurance, including a rule that health insurers must offer coverage to anyone who wanted to buy it – with prices varying by region and the age of the customer. Before the Affordable Care Act, a handful of states, including New York, protected people with pre-existing conditions, but most states did not. So, people with prior illnesses like asthma, cancer, heart conditions and even acne, often had trouble buying insurance for themselves and their families.
But the ACA prohibited that by requiring everyone to purchase insurance, known as the individual mandate. It accomplished this through two provisions: guaranteed issue, which means insurance companies must sell insurance to anyone who wants to buy it, and community rating, which means that people within the same geographic area who buy similar insurance and are the same age, pay similar prices. The two together made insurance affordable for people with, say, cancer. Before passage of the ACA, even minor health problems could have led an insurance company to deny coverage.
But Obamacare was a complex law, with many controversial provisions, and was approved almost exclusively by Democrats in both the House and Senate, getting only a handful of Republican votes.
Under GOP control from 2014 until 2018, lawmakers in the House and Senate tried at least 70 times to repeal, modify or otherwise curb the ACA since its inception as law on March 23, 2010. Over that time, its popularity ― especially specific provisions like pre-existing conditions, and providing for coverage up to the age of 26 ― grew in popularity.
In January 2017, one week before Donald Trump took over at the White House, he reiterated a campaign pledge made often, that his first legislative priority was to "repeal and replace" the entire Obamacare law. The U.S. Senate, in a series of budget votes, approved the repeal of the Affordable Care Act.
The next week, when Trump was sworn in, he signed an executive order on his first day in office, that according to then-White House Press Secretary Sean Spicer, would "ease the burden of Obamacare as we transition from repeal and replace."
In May of 2017, the Republican-controlled House voted to repeal most of the ACA by a narrow 217-213 margin and sent it to the Senate. But in a stunning defeat for President Trump and the GOP, the Senate voted down its own slimmed-down version of repeal, in a vote, in which Sen. John McCain, R-Az., famously held down his thumb late at night to doom the bill, 49-51. Not only didn't Republicans succeed to repeal the Affordable Care Act, but they never did offer a truly comprehensive replacement proposal.
Working with Senate Republicans, the Trump administration has tried to weaken rules that require insurance to cover a standard set of health benefits, called essential benefits – things like prescription drug coverage, maternity coverage and mental health coverage, among others. But so far, the Senate has not been able to muster a majority to vote for any of the repeal bills, in part because of public concern about the erosion of these popular protections.
Plans and proposals
To his credit, Trump signed a law eliminating the tax penalties for Americans who go without health insurance, known as the individual mandate. Passed strictly by Republicans on a party-line vote, it eliminated the penalty included in the ACA for failure to maintain health insurance coverage. Striking that provision has led to an ongoing court case that could eliminate the entire Obamacare law, currently moving its way through the nation's courts.
The administration has also been trimming the protections for pre-existing conditions, by allowing short-term, limited-duration health plans to expand their duration to 12 months, with renewals that last up to three years. Until recently, that limit was three months and it had been established to protect consumers from winding up with huge medical bills from an unexpected crisis. But the Trump administration argues these plans, as well as association health plans (AHPs), which are oriented to small businesses and sole proprietors, are less expensive alternatives to individual health insurance purchased through the exchanges created by the ACA.
The short-term plans are not required to cover people with pre-existing conditions, while the AHPs do. Neither of these plans are required to offer the ACA's essential health benefits.
Trump, in recent speeches, has also been touting a 2017 bill sponsored by House Republicans that would allow states to get waivers to allow insurers to charge much higher premiums to people with pre-existing conditions, if it became law.
President Trump has promised repeatedly to release a new health plan, but has never released any such detailed plan, nor even discussed its broad outline. He has made a series of promises about what a future plan might include, tweeting "far lower premiums & deductible."
"Medicare for All," a proposal endorsed by more than 100 Democratic House members and two major presidential candidates, Sens. Bernie Sanders, D-Vt., and Elizabeth Warren, D-Mass., would reshape the health system by eliminating private health insurance and replacing it with generous government coverage funded with tax revenues. The remaining Democratic presidential candidates support maintaining and updating the Affordable Care Act or moving to Medicare-for-all over time in incremental steps but offering everyone a chance to keep their private insurance.
What’s not in it for seniors in the 2021 budget proposal
Trump's recent statements about not touching Medicare, Social Security and Medicaid also don't coincide with the budget his administration released in early February. In statements and tweets, Trump vowed "we will not be touching your Social Security and Medicare in fiscal 2021 budget."
But then the Trump administration unveiled a $4.8 trillion budget – a blueprint written under Washington rules as if he could enact it without congressional approval, which he can't – that wants to slash billions of dollars in federal support from Medicaid, food stamps and other safety net programs for the poor, while largely sparing the Medicare program that benefits seniors.
What's most notable about the budget is what's not included in it. In previous years, Trump's budget has proposed repealing Obamacare and replacing it with a system that would provide block grants of funding to states with far fewer rules about how the money should be spent. This new budget backs away from that, leaves the law's funding in place, but asks Congress to develop policies that would "advance the president's health reform vision."
It still makes major changes to health care programs, including several that would tend to lower federal spending on Medicaid. It does that, in part, by reducing the share of medical bills the federal government will pay for the Obamacare expansion program, and imposing new requirements on people who wish to enroll. But together, the combined Medicaid and Affordable Care Act cuts equal a trillion-dollars cut that would mean substantial program changes.
The budget avoids some political hot-button issues by not reducing Social Security or Medicare benefits. Most of the administration's initiatives on saving Medicare money are cost reduction proposals first offered under President Barack Obama.
The bottom line is that while it appears that the President says one thing and does another, Congress continues to control the actual spending of dollars, for the most part. The court case over the Affordable Care Act will be decided on the judiciary's timetable, so it's not clear how long the White House may have to develop a replacement plan.
When President Trump first tried to repeal the ACA, he said: "Nobody knew health care could be so complicated." With his re-election campaign under way, it's clear he knows it now.
Also contributing to this column: the New York Times, Politico, Washington Post, Vox.