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If anyone needed more evidence that Republicans are nervous about health care’s impact on this year’s midterm elections, the president provided it Thursday afternoon:

“All Republicans support people with pre-existing conditions, and if they don’t, they will after I speak to them. I am in total support. Also, Democrats will destroy your Medicare, and I will keep it healthy and well!” President Donald Trump tweeted Oct. 18.

In the real world, Trump’s Justice Department is arguing in court that the Affordable Care Act’s protections for pre-existing medical conditions are unconstitutional and should be nullified. On top of that, his administration explicitly supported a bill passed by House Republicans that would have weakened those protections.

Senate Majority Leader Mitch McConnell is also trying to have it both ways, claiming that Republican senators universally support protecting people with pre-existing conditions, while voicing his support for the lawsuit and another repeal effort.

Democrats recognize that the GOP is vulnerable and conflicted on health care, and its candidates are devoting millions of dollars worth of ads to it. It’s not the only thing helping to give Democrats a strong chance of taking back the House. But it’s a key driver.

Trump and McConnell are far from alone in touting their support for protecting pre-existing conditions while having voted or worked to dismantle the ACA. Many other candidates are doing the same tap dance, and are even running ads touting their support for the policy. The GOP candidates for Senate in tight races in Missouri and West Virginia are current attorneys general who are supporting the controversial lawsuit.

It’s easy to see why everybody’s anxious. The ACA’s robust protections for people with pre-existing conditions are highly popular. In a recent Kaiser Family Foundation poll, more than 70 percent of Americans agreed that it was “very important” that they remain law.

That gets at the heart of Republicans’ dilemma: It’s one thing to promise an end to Obamacare’s burdensome regulations while vowing to lower premiums and maintain patient protections. But it’s actually a phenomenally difficult policy problem, and the GOP hasn’t offered a proposal that solves it.

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The ACA prohibits insurers from denying coverage to people with pre-existing conditions and from charging them more for it, ensures that all plans cover a core roster of benefits including mental-health treatment and maternity care, and bans lifetime and annual coverage limits. It supports those protections and insurers by attempting to create a large risk pool and subsidizing insurance for people with lower incomes.

If you cut out any part of that, the door likely opens for insurers to offer skimpier insurance, siphon off healthy people, and leave those with pre-existing conditions with less appealing or more expensive options. The administration is currently doing that on a smaller level by pushing cheaper but less comprehensive short-term insurance plans.

It’s theoretically possible to protect people with pre-existing conditions in other ways. But they almost certainly involve trade-offs. The one that the GOP has generally tended to favor recently is weakening protections for people with pre-existing conditions in order to lower costs for healthy people.

No GOP candidate wants to say that out loud, to admit that their definition of protection is different and less comprehensive than the status quo. Democrats are spending a lot of money to make the distinction clear.

Pre-existing conditions aren’t the only health-care sore spots for the GOP.

In past years, Republicans have run on the idea that Obamacare’s individual market is an irredeemable failure, bolstered by soaring premiums. But premiums have stabilized or declined and insurers are increasingly profitable, making it more difficult to assail the law. Premiums would be lower if the GOP hadn’t spent years deliberately undermining the market.

And referendums on the law’s Medicaid expansion, which has dramatically expanded coverage for vulnerable Americans in more than 30 states, are on the ballot in Utah, Nebraska, and Idaho. It’s implicitly on the ballot in others, where changes in the composition of state governments could push states toward expansion, or in the other direction toward Arkansas-style work requirements that push people off of the program.

If the House flips and Democrats hold Senate seats in West Virginia and Missouri, states that Donald Trump won by 42 and 19 points respectively, it’s a sign that the GOP needs to rethink its approach to health care.

— Max Nisen is a Bloomberg Opinion columnist covering biotech, pharma and health care. He previously wrote about management and corporate strategy for Quartz and Business Insider.

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