The Wall Street Journal, The Washington Post, CBS News and other news outlets have led with headlines touting the big news that Donald Trump is willing to keep parts of the Affordable Care Act — notably the pre-existing condition protections and the ability for children up to the age of 26 to stay on their parents policies.
In May, Trump’s policy advisor told Healthline that a Trump administration would consider keeping the children to age 26 provision.
And, then there is this February debate exchange between Trump and a CNN moderator:
TRUMP: “I want to keep pre-existing conditions [the Obamacare provision that prohibits insurers from denying coverage]. I think we need it. I think it’s a modern age. And I think we have to have it.”
DANA BASH: “Okay, so let’s talk about pre-existing conditions. What the insurance companies say is that the only way that they can cover people is to have a mandate requiring everybody purchase health insurance. Are they wrong?”
TRUMP: “I think they’re wrong 100 percent … We should have gotten rid of the lines around each state so we can have real competition … we should have gotten rid of the borders; we should have gotten rid of the lines around the state, so there’s great competition. The insurance companies are making a fortune on every single thing they do. I’m self-funding my campaign. I’m the only one in either party self-funding my campaign. I’m going to do what’s right. We have to get rid of the lines around the states so that there’s serious, serious competition …”
BASH: “But, just to be specific here, what you’re saying is getting rid of the barriers between states, that is going to solve the problem …”
TRUMP: “That’s going to solve the problem … Look, the insurance companies are making an absolute fortune. Yes, they will keep preexisting conditions, and that would be a great thing. Get rid of Obamacare; we’ll come up with new plans. But, we should keep preexisting conditions” …
Trump’s argument about “getting rid of the lines,” or letting carriers sell across state lines, is another matter, but Trump was pretty clear back in February — ” they [the health plans] will keep preexisting conditions.”
That begs the question, How can we get rid of the dreaded Obamacare individual mandate and the fines for not buying coverage while forcing health plans to cover people with pre-existing conditions?
Trump was right when he said we don’t need the individual mandate to still cover people with pre-existing conditions. There are a number of ways to get people covered and give them the incentive to stay covered:
Republicans have consistently proposed state-run high-risk pools as a place for those who fall out of coverage could go to get coverage — albeit from the high-risk pool, not the insurer. But that would mean segregating these people into state-run pools that have a long history of being underfunded, expensive for consumers, burdened with limited benefits, and enrollment caps.
The most cost efficient way to do it — and do it in mainstream health insurance — is to require health plans to cover these people as we do now but permanently protect the health plans from their costs through a self-sustaining revenue neutral risk pool. Such a reinsurance pool could be created from an assessment on all individual health insurance market premiums and allocated to the carriers based upon such claim costs.
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But a wide-open mandate to cover sick people, other than during periodic open-enrollment periods, would only let the sick come and go as they please leading to unsustainable costs — not unlike what we have in the Obamacare exchanges today because the individual mandate is not being consistently enforced.
The mandate and accompanying fines aside, to keep the cost of these pre-existing claims manageable there would still have to be some sort of enforceable incentive for people to stay covered.
In the past, I have suggested a provision that eliminated the individual mandate and penalties thereby enabling consumers to join at anytime beyond their initial eligibility date, and get themselves and their families covered for any prospective illness. To create the incentive to stay covered and stop revolving door enrollments, I would exclude any pre-existing condition for a year. I would let people access their insurers provider discounts for these pre-existing conditions during their waiting period.
Others have suggested that late enrollees pay a higher premium as we do under the Medicare Part D program now. However, any surcharge that approximated the cost of late enrollment would likely be quite high.
So, as you can see, there is no way to really cover all pre-existing conditions without a strong incentive to get covered when first eligible, and stay covered.
But the real key to getting pre-existing conditions covered is to provide people with attractive, affordable health insurance in the first place.
For decades, the employer market worked well, and it did not have an individual mandate because people were offered attractive and affordable plans. Employees consistently enrolled, and they stayed covered for decades before Obamacare. Much of this issue goes away if people are offered affordable and attractive insurance.
So, Trump’s declarations on this are not new. Sorry, but there is no reason for big headlines about him backtracking on what he said he would do with health care.
Robert Laszewski is president, Health Policy and Strategy Associates and blogs at Health Care Policy and Marketplace Review.
Image credit: Shutterstock.com
