Trump’s—and the GOP’s—Hat Trick of Falsehoods About Pre-Existing Conditions

Last week, USA Today published an op-ed by Donald Trump in which the president attacked Democratic proposals to create a system of Medicare for All. Despite using complete sentences and correct spelling, the essay was recognizably Trumpian: it stoked fears in his disproportionately elderly supporters through tendentious assumptions and outright lies. As Glenn Kessler observed in the Washington Post, “almost every sentence contained a misleading statement or a falsehood.”One of the biggest whoppers was Trump’s claim that he has kept his campaign promise to “protect coverage for patients with pre-existing conditions.” That claim was triply dishonest. First, the administration is backing a lawsuit that would eliminate the current prohibition on insurers’ screening out people with pre-existing conditions. Second, the Republicans’ alternative would not provide real protection. Third and most telling, by accepting the logic of protecting patients with pre-existing conditions, Trump and the GOP give the lie to their red-baiting on Medicare for All.The Affordable Care Act and its DiscontentsThe Affordable Care Act (ACA) has grown more popular over time, but its provision barring insurance companies from denying or charging extra for coverage of people with pre-existing medical conditions was popular from the start. Meanwhile, the ACA’s least popular provision—the so-called individual mandate that most people without another form of health insurance purchase a policy—was always closely tied to the pre-existing conditions provision.How so? Based on the experience of various states before 2010, Congress had good reason to fear an adverse selection problem. If the ACA did not contain a mandate but did bar insurance companies from rejecting customers based on pre-existing conditions, then many young healthy people would choose to go without health insurance, knowing that they could always buy a policy later if they got sick. That, in turn, would starve insurance companies of premiums sufficient to pay for care. Combined with government subsidies, the mandate solved this problem by putting enough people in the health insurance pool to provide a viable market.The ACA survived two Supreme Court challenges by 5-4 votes, first in a constitutional case in 2012 and again in 2015 in a statutory case. However, late last year, Congress seriously undermined the ACA by reducing to “$0” the tax that people who fail to obtain health insurance under the mandate must pay. That provision will become effective next year, and whether it will send the individual insurance market into a death spiral remains to be seen.Meanwhile, the Trump administration is not taking any chances. It has slashed funding for efforts to promote the ACA; with the backing of all but one Senate Republican, it has expanded the availability of insurance plans that provide minimal coverage, thereby undermining the pool for fully ACA-compliant plans; and in direct contradiction of the president’s claim to care about insurance for people with pre-existing conditions, it has lent its support to