During the presidential debate with Vice President Kamala Harris, former president Donald Trump famously claimed that he had a “concept of a plan” for health care.
For those who do not remember, this “concept of a plan” is after running in 2016 on wanting to “repeal and replace” the Affordable Care Act. After negotiating unsuccessfully with congressional Democrats in 2017 to try to do just that. After running for reelection in 2020. And again in 2024.
A concept of a plan to address something that we all need at some point or another: health care.
Like most Americans, I thought it was an amusing line. Or would have if it pertained to a policy domain other than health care. But I remember what it was like to have health care on the line in 2017.
I wrote an op-ed in The New York Times, putting on my political science hat. I called my congresswoman and senators at the time (all Democrats who were voting correctly but I wanted my voice heard). I participated in health care rallies in New York City around the Senate vote.
For many people such as myself, it’s life or death. And it doesn’t feel that long ago that I was asking my doctor not to document certain conditions, or not to run certain tests. It doesn’t feel that long ago that I got denied coverage due to my childhood medical condition (I was born with a kidney disorder that resolved in my late teens). I doesn’t feel that long ago that I was dropped from coverage for not disclosing that I simply had irregular periods (without a serious underlying cause).
According to J.D. Vance, the campaign does in fact have more than just a concept of a plan. The problem is what that plan entails: The rescission of protections for the millions of Americans with preexisting conditions. (The Kaiser Family Foundation estimated in 2019 that approximately 27% of non-elderly Americans, or 54 million, have a previously declinable preexisting condition.) To be more specific, Vance kvetched about having a single risk pool, which is what allows us to keep premiums down for people with significant medical histories. Bring back high-risk pools, and people with preexisting conditions will be charged exorbitant premiums that are likely prohibitively expensive, leaving them vulnerable.
This is, not too surprisingly, an approach that would be deeply harmful if implemented, and it is almost impressive in its absurd combination of bad politics and bad policy, and it leaves patients more vulnerable than pre-Affordable Care Act implementation.
Rescinding these protections is bad politics
At the time of its passage, the Affordable Care Act was not especially popular, garnering 46% support in the Kaiser Family Foundation tracking poll in April 2010. This was seen perhaps most prominently in the 2010 midterm elections, with the Democrats losing control of the House of Representatives and several Democrats losing their seats specifically because of their votes in support of the ACA.
But the public opinion tides have turned considerably over the years, especially once Trump took office and the ACA appeared imperiled (48 favorable/42 unfavorable in February 2017 as Republicans took up what would become the American Health Care Act). As of May 2024, a whopping 62% of Americans have favorable impressions of the ACA.
Of course, these numbers come with the caveat that support for the ACA largely falls along party lines. But that’s not true of all of its components – namely, the provision protecting people with preexisting conditions from being denied coverage. In its February 2024 survey, the Kaiser Family Foundation found that majorities in both parties viewed it as “very important” to prohibit health insurance companies from denying coverage due to a patient’s medical history (79% among Democrats, 66% among independents, and 54% among Republicans). Similar numbers were seen regarding a prohibition against charging sick people more for coverage. While the share seeing the guaranteed issue provision as very important has indeed declined since measured in July 2019, it’s still striking that this is a health policy issue that unites the parties.
Except for the presidential ticket, that is. Having seen this favorability of one of the ACA’s core provisions, it is perhaps less surprising that law professors Abbe Gluck and Thomas Scott-Railton characterized the ACA as “the most challenged – and the most resilient – statute in modern American history.” Which is to say, though it does not enjoy the degree of entrenchment of Medicare, it certainly seems to have nine lives.
If I were advising a presidential candidate, I can’t say that that’s the issue I’d take on in a hotly contested election. It’s bad politics. And after seeing significant gains in insurance status, financial protection, and health outcomes, trying to take that away is – to quote Tim Walz – just plain weird. Which brings us to policy…
Rescinding these protections is bad policy – and it would be worse than pre-ACA
Prior to the implementation of the Affordable Care Act, a large share of the nonelderly population -- 9 to 19% depending on the specific question asked – went without health care due to cost, and it won’t take a lot of asking around to find someone who avoided going to the doctor out of fear of having a new declinable medical condition documented. What’s more, 48.6 million Americans were uninsured.
Now, an uninsured rate of 16% is practically unthinkable. (It is currently 8%.)
In addition to dramatically bringing down the number of uninsured individuals, we’ve seen improved access to care: currently about 88% of Americans have a usual source of care. Compare that to 2010 (the year of the ACA’s enactment), when 80% of the privately insured had a usual source of care but only 44% of the uninsured did. And those who are using their health insurance plans have decreased out-of-pocket expenditures.
One of the less discussed aspects of contemporary health policy reform proposals is that we would not simply be rolling back the clock to 2010. Because with this improved access to care has come more documentation of medical conditions that may otherwise have gone undiagnosed.
Take, for example, a previously uninsured patient who has not seen a doctor in years despite not having felt well. With expanded health insurance options under the ACA, they finally see a doctor and learn that they are diabetic. Diabetes is a previously declinable preexisting condition that might not have been documented but for the ACA. To rescind these protections is to penalize patients for availing themselves of a new health insurance option, when we know that the alternative of uninsurance is associated with worse health and financial outcomes for the patient (not to mention uncompensated care to providers).
What’s more, over the last several years we’ve battled the global pandemic of COVID-19. While to be sure, not all COVID cases required significant medical treatment, we know that many patients were hospitalized, even put on ventilators. People faced various complications. We also know that apart from actual COVID treatment, the pandemic had broader ramifications, such as increased alcohol and drug abuse, and high rates of reporting of depression and anxiety that placed mental health providers in increasing demand. And with recent drug or alcohol abuse treatment and severe mental illness all constituting previously declinable preexisting conditions, there are real vulnerabilities for those populations hard hit by the pandemic.
The last domain in which things are fundamentally different than 2010 is pregnancy and for that, we can thank the United States Supreme Court. Prior to the enactment of the ACA, women enjoyed reproductive freedom. Yes, states could enact restrictions so long as they were not unduly burdensome under Planned Parenthood v. Casey, but at least through the first trimester, for the most part women had freedom. (The bigger challenge was finding a provider, which could be hard to come by in certain parts of the country.) That is no longer the case, and the post-Dobbs v. Jackson world is more restrictive than pre-Roe, with some red states passing bans that lack basic exceptions such as for rape or incest. What these sweeping abortion restrictions mean is that women have less autonomy over when they carry pregnancies to term, meaning they may have pregnancies that are less healthy and safe. While EMTALA (in theory) allows for the termination of life-threatening pregnancies even in states where abortion is banned, that does not account for the broader constellation of challenges that may arise and complicate one’s medical history, and there remains some degree of vagueness as to the parameters of when intervention is acceptable. This creates a new dimension of precarity for women in the setting of proposed health insurance reform.
In Conclusion
When it comes to policy, Trump is, shall we say, not a deep thinker. In 2016, he pledged a “beautiful” plan for health care, which he claimed no one knew was so complicated. In 2024, it’s a “concept of a plan.”
So far, the concept deserves a failing grade. And patients with chronic or acute medical problems can’t afford to relive 2017, especially considering that the repeal effort was only foiled by a single Republican senator who is no longer alive and who was within a Republican coalition that no longer exists in Congress.
We are at the stage of the campaign during which Trump and Vance will happily make empty promises – whether compelling insurance coverage of IVF (something something limited government?) or the next thing that pops into Trump’s head – to score a few extra votes in Pennsylvania and Michigan, so we’ll see if this policy sticks. Indeed, given the bad politics of the proposal, it’s surprising that this is what Vance has led with (though it is consistent with Vance’s, um, less than helpful presence on the ticket). But if there’s anything we’ve learned from the health insurance battle of 2017, it’s that when hearing a proposal to gut a central component of the ACA, American patients should take him both seriously and literally.
Fabulous piece! I have to wonder whether Harris knew this at the debate (because it would have been great for her to say that Trump's "concept" will bring back the pre-existing condition limits). Also interesting that this has not been headline news in legacy papers. I read a lot...but your piece is where I am learning the details.