Vance revives old GOP fights on ObamaCare insurance coverage

Republican vice presidential nominee Sen. JD Vance (R-Ohio) on Sunday floated an idea that would turn back the clock on covering people with preexisting conditions, relitigating a position that was a hallmark of GOP proposals to replace ObamaCare during Donald Trump’s presidency. 

In an interview on NBC’s “Meet the Press,” Vance said Trump’s health plan would “promote choice” in the health system by separating sicker people into different health insurance coverage pools from the healthier populations. 

Vance said Trump’s health plan would focus on deregulating the insurance markets to “not have a one-size-fits-all approach that puts a lot of people into the same insurance pools, into the same risk pools” while also making sure that people have access to the doctors and care that they need.

Vance’s comments come after Trump said on the debate stage last week that he had “concepts of a plan” to replace the health law if it were repealed. 

In attempting to fill in the blanks of Trump’s plan, Vance described the same “high-risk pools” championed by conservatives in the House when they were crafting an ObamaCare replacement bill in 2017. 

For more than 35 years prior to passage of the Affordable Care Act, red and blue states alike used high-risk pools to cover people with expensive medical conditions separately from the rest of the insurance market.  

According to insurance experts, the general idea of a high-risk pool is to pull out of the market the sicker people who are a higher cost in order to reduce premiums for the healthy people who are in the regular market. 

But the pools rarely succeeded in covering people who needed insurance the most. They lacked sufficient funding, so people usually saw high premiums and limited coverage. 

“When you only have sick people in one separated pool, those premium costs are going to be extremely high, unless they are subsidized, or unless the benefits are really skimpy,” said Sabrina Corlette, a research professor at Georgetown’s Center on Health Insurance Reforms. 

“Unless you’re willing to throw a lot of taxpayer dollars to subsidize these high-risk pools, they are high-priced, crappy ghettos for people with preexisting conditions,” she said. 

Still, conservatives pushed the idea as a replacement for what they said was ObamaCare’s “one size fits all” mandate that established a single risk pool for everyone.  

They wanted states to be able to opt out of the law’s “community rating” requirement, which forbids insurers from charging sicker people more money.  

Nearly all state high-risk pools excluded coverage of preexisting conditions anywhere from three months to a year and then charged exorbitant premiums — if they covered the person’s condition at all.

Many state pools had lifetime caps on covered services, and some even had annual dollar limits on specific benefits, meaning a cancer patient or someone with diabetes who needs expensive drugs wouldn’t be able to have those covered.

After the GOP repeal bill failed in 2017, ObamaCare became increasingly popular. 

“At this point, every political leader says people with preexisting conditions should be protected, but that doesn’t always mean the policies they advocate will accomplish that,” Larry Levitt, executive vice president for health policy at KFF, said in an email.  

Yet, the push to create high-risk pools lives on in high-profile conservative circles.   

For instance, the Republican Study Committee’s (RSC) fiscal 2025 budget proposed removing many of the existing protections for people with preexisting conditions, including allowing states to offer separate risk pools for younger, healthier people.   

The RSC also proposes to bring back medical underwriting — the ability for insurers to assess a person’s health risk and charge higher premiums or exclude certain benefits from plans purchased by people with preexisting conditions.  

The RSC represents 80 percent of House Republicans. 

“In theory, segregated high risk pools could adequately protect people with preexisting conditions and keep their premiums affordable, but that would only be true if there’s sufficient government funding for those pools,” Levitt added. 

But Republicans are largely opposed to more government spending, so it’s not clear where the resources to cover those people would come from.