Update, Wednesday, Oct. 2: This article has been updated to include comments from the Oct. 1 vice presidential debate.
Memorably, former President Trump mentioned “concepts of a plan” when asked about his proposal to reform healthcare at last month’s presidential debate. But in the days leading up to and during Tuesday’s vice presidential debate, Trump’s running mate, Sen. JD Vance, says there is a plan to “fix healthcare,” specifically with respect to the Affordable Care Act.
Vance has argued that the health insurance market needs to be deregulated. He has spoken of placing people with chronic conditions into separate insurance pools. But this could lead to insurers charging higher premiums for individuals with pre-existing conditions.
During the Oct. 1 vice presidential debate, Vance appeared to walk back his previous statement a bit by saying he was referring to reinsurance, or a way in which the government could insulate itself from the risk of high-cost claims. He went on to state that Trump favors the idea of permitting “states to experiment a little bit on how to cover both the chronically ill and non-chronically ill.”
Kamala Harris’ campaign released a report on Monday that maintained that millions of people with preexisting conditions could lose protection guaranteed them by ACA rules if the changes Vance and Trump are proposing go through. Her running mate, Minnesota Gov. Tim Walz, emphasized that point at Tuesday’s debate.
Vance responded that he and Trump plan to keep in place the existing laws and regulations protecting those with preexisting conditions. He did not, however, explain that those laws are within the ACA.
At the debate, Vance also defended Trump as having “saved” the ACA. But, as Walz pointed out, during his term in office, Trump sought to undo ACA by executive action, legislation and lawsuits. The law survived. And during Trump’s bid to secure a second presidential term, he has wavered on the idea of whether to repeal the ACA.
Perhaps given the fact that the ACA is popular and growing in terms of enrollment and the uninsured rate is at an historic low, rather than do away with the ACA, Trump is now calling for what he describes as improvements in the law.
However, Vance is proposing substantial changes to ACA health insurance coverage that could lead to the elimination of the ACA’s protection against insurers levying higher premiums on individuals in poor health.
Vance has spoken of deregulating the insurance market so that “people can choose a plan that actually makes sense for them,” as reported in The Hill. On the campaign trail in North Carolina last month, for instance, Vance suggested getting rid of the ACA’s single-risk pool which enables community rating and introducing separate risk pools for people with chronic health conditions. This would disrupt one of the ACA’s guiding principles which states that health insurers may not charge people higher premiums based on their health status.
KFF estimates that 27% of adults have a condition that would have led to denied coverage by an insurer in the individual market before the ACA. Prior to the law’s passage, insurers were able to deny coverage for a wide range of diseases and conditions or charge substantially higher premiums for individuals with preexisting conditions.
Vance has said he wants to leave decisions on how to regulate what insurers do with the aforementioned high-risk insurance pools up to individual states. Subsequently, if certain states permit premium surcharges based on health status, people with preexisting conditions would theoretically have access to health insurance, but it could be unaffordable.
State high-risk pools could provide access to coverage to people with preexisting conditions as an alternative to the private insurance market. But whether such pools would be effective depends on adequate funding, which did not occur in the states that had instituted them before the ACA was enacted. And so these insurance pools were not a feasible option for many due to exorbitant premiums.
On the stump, Vance has also said “we’re going to actually implement some regulatory reform in the healthcare system that allows people to choose a healthcare plan that works for them. If you only go to the doctor once a year, you’re going to need a different healthcare plan than somebody who goes to the doctor 14 times a year because they’ve got chronic pain or they’ve got some other chronic condition.”
Though it’s unclear what in particular Vance has in mind for healthier individuals, maybe he’s referring to short-term insurance plans, which the Trump Administration promoted and made more accessible. These options do not offer coverage as comprehensive as ACA plans. Some healthy people might have an incentive to opt for short-term insurance, which can be renewed every three to 12 months, as a way to lower premiums.
The problem is that this may drive up costs considerably for the sicker folks who remain on ACA exchange plans. Moreover, the idea of offering healthy individuals a cheaper plan with far less complete coverage tacitly presumes that people’s health needs are static, which they often are not. Perhaps the most important aim of having health insurance is to provide financial protection from unforeseen events. The fact that a person only sees a doctor once now has no bearing on the future, whether that’s next year or later.
Only 39% of survey respondents polled by KFF in February of this year were aware that the ACA prohibits insurers from denying coverage to those with preexisting conditions, and only 31% knew that the ACA also prevents sick people from being charged higher premiums than healthy individuals. In light of Vance’s statements on ACA reform, it would seem important that the electorate be better informed about what the proposed changes could entail.
