Candidates are jumping over each other to get on the pre-existing conditions bandwagon

What gives this election cycle? Suddenly we’re in the midst of a surprising debate over health insurance and preexisting conditions again. Is this 2018 or 2010?

The public as a whole has always been split on the Affordable Care Act since it passed eight years ago, and a significant portion of Americans continues to have an unfavorable opinion of the law. But this year there’s a huge shift in how the general public regards certain provisions of the ACA, as evidenced by the latest crop of political ads. According to the Wesleyan Media Project, nearly half the ads in House and Senate races mention health care and almost one-third of ads in gubernatorial contests did.

What’s more, the ads are coming from both Democrats and Republicans who want to be seen as friends of health insurance for sick people. In Michigan, Democrat Elissa Slotkin is running against GOP Rep. Mike Bishop for Congress. In one of her ads, she talks about her own mother’s death from ovarian cancer as well as her mother’s earlier struggle with breast cancer. She calls Bishop’s vote last year to repeal the ACA a “dereliction of duty” and a “fireable offense.” As Jesse Ferguson, a Democratic campaign strategist, told Roll Call, voters are looking for authentic voices. For these candidates, pre-existing conditions are not a “talking point. It’s real life.”  

Wisconsin Gov. Scott Walker, no friend of health reform, also seems to be saying he’s for covering pre-existing conditions. He tells viewers this is personal for him because his mother had cancer, his wife is a Type 1 diabetic, and his brother has a heart condition. “As long as I’ve governor, I will always cover pre-existing conditions,” he says.

Does that mean Walker will work with his state insurance department to make sure all policies sold in Wisconsin must cover people who are sick? His campaign ad doesn’t go there. But that’s a good question Wisconsin reporters should be asking.    

Pre-existing conditions as an issue are so potent that even Republicans who have signed on to a Texas lawsuit that would eliminate coverage for pre-existing conditions are insisting they support coverage for sick people, as Missouri Attorney General Josh Hawley has done in his battle against Sen. Claire McCaskill. As the state attorney general, Hawley added his state’s name to the Texas case.

But in a 30-second ad, he says, “Earlier this year, we learned our oldest has a rare chronic disease, a pre-existing condition. We know what that’s like. … I support forcing insurance companies to cover all pre-existing conditions.”

How far we’ve come since I wrote a lengthy report in 1990 called “The Crisis in Health Insurance” for Consumer Reports! Those stories revealed the unfairness of the practice of denying health coverage to the very people who needed it — those who were sick. It detailed the unsavory practices of insurance companies that made it impossible for sick people as well as those working in dangerous occupations to get insurance. Back then this issue hardly generated the outrage among the public that it does today.

We still have a crisis of affordability in health insurance. But the Affordable Care Act, despite its shortcomings, has brought about a broad shift in the public’s thinking. Today most people believe that a pre-existing condition shouldn’t prevent you from being able to buy health coverage in the individual market. Anything less is unacceptable. It’s the proverbial sea change.

Medicaid, too, has gained more respectability. The program passed in the mid-1960s has always been a stepchild in the health care family because it’s for the poor. But there was been widespread news coverage of the 17 states that have so far refused to expand their Medicaid programs under Obamacare. That in turn has meant some of the poorest Americans have had no other options for medical care. More people have come to think of Medicaid as an essential safety net as a result.

A year ago, when members of Congress still held town hall meetings, it was common to see signs of support for Medicaid held by those in the audience. As someone who has covered this issue for a long time, it was astonishing to see that.

This year, three conservative states — Utah, Idaho, and Nebraska — have ballot proposals that would expand Medicaid by bypassing their state legislatures. “I think we’re at a fork in the road,” Fred Birnbaum, vice president of the Idaho Freedom Foundation, the main group fighting the referendum in that state, told Politico. “If Idaho and Utah and Montana and Nebraska and other states expand Medicaid, it will be harder for Congress to reverse that. I think that is going to put us on the path to a single payer system.” 

If these states expand Medicaid, many more vulnerable Americans formerly marooned by geography will have health insurance. 

Monday’s announcement from the Trump administration is guaranteed to keep pre-existing conditions in the election spotlight, perhaps even after the election is over. The controversial proposal gives the states the flexibility to set up two insurance marketplaces — one with low premiums to attract healthy people and the other for sick people who will pay much more for their coverage. In both markets, consumers would receive tax subsidies to help pay the premiums, just as Obamacare policyholders get now. As Jonathan Cohn noted in his Huffington Post story, “ the rule change almost certainly means that people with serious medical problems are likely to have a harder time finding coverage — and ultimately paying their medical bills.” The subsidies from premiums paid by healthy policyholders will no longer be enough to cover the costs of the new pool of sick applicants.

More Americans are coming to believe that health care is a basic right. Time will tell how well the administration’s move to create a two-tier health system in the individual market will actually play out. Perhaps the election results will show that Americans increasingly believe it’s unacceptable for insurance companies to turn down people with serious health conditions — and even those with minor ones like acne. Do Americans want health insurance system that penalizes people simply because they happened to get sick at some point in their lives? Will Republican attempts to persuade voters of their newfound passion for pre-existing conditions succeed? 

The election should help us answer these questions. It will almost certainly shape the kind of health insurance Americans will be able to afford in the years to come.  

Veteran health care journalist Trudy Lieberman is a contributing editor at the Center for Health Journalism Digital and a regular contributor to the Remaking Health Care blog.