While the House and Senate plans did include funds for states to create “high-risk pools,” which would subsidize coverage for those requiring more medical care, such pools have been tried in about 30 states and have uniformly failed. States found that they could not allocate anywhere near the amount of money necessary to make coverage affordable for patients with preexisting conditions, and experts say the plans’ funding was equally inadequate. “The cost would have to be tremendous, and that is precisely because of the skewed distribution of health-care spending,” Blumberg said. “In order to make that coverage affordable for the people who need it, you would have to throw huge amounts of money at those pools.”
More recently, many Senate Republicans have rallied behind 2019 legislation from Senator Thom Tillis, who is facing a tough reelection fight in North Carolina. His bill declares that insurers must continue selling coverage to patients with preexisting conditions at comparable prices to what they charge other consumers. But the bill contains huge loopholes that undermine that promise. It allows insurers to limit the benefits provided in such coverage, which could exclude the treatments a patient needs. It also doesn’t maintain the ACA’s limits on out-of-pocket costs, or its ban on annual and lifetime benefits caps, which means those with substantial health problems could easily generate bills that exceed their coverage. All of those provisions provide insurers “another way of excluding coverage of preexisting conditions,” Sarah Lueck, a senior policy analyst for health care at the Center on Budget and Policy Priorities, told me.
Meanwhile, with repeal of the ACA again wending its way through the courts, Trump has tried to advance the GOP goal of unraveling risk-sharing through regulatory action. His administration has authorized insurance companies to sell more short-term plans that are exempt from the ACA’s requirements to cover patients with preexisting conditions and offer comprehensive benefits. Those plans provide an escape route for healthier consumers to buy cheaper coverage, which could tilt the general individual market more toward the sick, raising their premiums.
The paradox in the contrasting GOP and Democratic approaches, as I’ve written, is that the Democratic plans ask more of the young—who mostly vote for Democrats—while the Republican plans impose greater costs on older Americans, most of whom are white and have leaned toward the GOP for the past few decades.
Biden’s proposals to significantly increase federal subsidies for consumers purchasing insurance in the ACA marketplaces represent a tacit admission that the law’s original design may have asked healthier consumers to shoulder too much of the cost of ensuring coverage for those who are older and sicker. Expanding subsidies could also entice more younger and healthier people into the insurance market, which would help restrain costs. By contrast, Trump and other Republicans are still resolutely denying the inescapable reality that their proposals will increase costs and reduce access for the sick, not as an unintended consequence, but as the central lever to lower premiums for the healthy.