WASHINGTON — Polls show that health care is one issue dominating voters’ minds as they prepare to cast their midterm ballots.
It’s a topic represented heavily in campaign messaging for candidates on both sides of the aisle. In particular, what to do for Americans with pre-existing health conditions is shaping up to be a potent question in races across the country.
House Republicans stress that their bill to repeal and replace the Affordable Care Act would have retained the popular requirement that insurance companies cover people with pre-existing conditions.
But Democrats say the GOP took steps in that legislation that would have made the protections weaker.
Health care experts say the protections in the Republicans’ bill would be less robust than under the Affordable Care Act and rely in part on how far states would go to uphold them.
The focus on health care is clear in two swing races in the Omaha-Council Bluffs area — Nebraska’s 2nd District race between Rep. Don Bacon and Kara Eastman and the Iowa 3rd District contest between Rep. David Young and Cindy Axne.
GOP incumbents, including Bacon and Young, have defended their support of legislation to repeal and replace the Affordable Care Act. The bill passed the House but fell short in the Senate. Supporters of the measure argue that it would have addressed flaws in the ACA and helped rein in rising insurance premiums.
Democratic challengers, meanwhile, are promoting their own proposals — from new public insurance options to a “Medicare-for-all” system — and focusing on how the GOP plan would have affected the Affordable Care Act requirement that insurance companies take all comers and sell coverage of essential health benefits to everyone at the same price, regardless of their medical history.
That requirement prevents people from being denied coverage as a result of past illnesses or chronic ailments, but it also tends to drive up insurance premiums for younger, healthier people.
Republicans stress that their bill would have retained the requirement that insurance companies cover people with pre-existing conditions. But they took a different approach that Democrats and others say may not protect everyone, especially when it comes to premiums.
During debates against Bacon last week, Eastman said the Republican bill would have allowed states to raise prices on those with pre-existing conditions such as diabetes, asthma or cancer.
“The idea that health care would cost more for them is simply un-American and just not the way that we should be developing our health care system,” Eastman said during a debate at the Omaha Press Club.
Bacon, in his first term, said the GOP legislation had multiple protections for those with pre-existing conditions.
“It’s very important for a moral country — (to have) affordable health care and to protect pre-existing conditions,” Bacon said.
Across the river, Young has voted various times over the years to repeal the ACA. He supported the final version of last year’s GOP House repeal-and-replace measure.
Axne has run ads saying Young’s support for the bill gutted protections for those with pre-existing conditions, while Young says he stood up to his party on behalf of those people, in part by fighting for an extra $8 billion in funding to help the situation. That money could be used for efforts such as state-level high-risk pools.
The importance of the issue was reflected in a recent tweet by President Donald Trump.
“All Republicans support people with pre-existing conditions, and if they don’t, they will after I speak to them,” Trump wrote. “I am in total support.”
While the Republican health care bill stated that pre-existing condition protections should be continued, it would have indirectly weakened those protections in a couple of ways, according to Karen Pollitz, a senior fellow at the Kaiser Family Foundation, which studies health care and insurance.
For example, it would have allowed higher premiums to be charged on those with pre-existing conditions who don’t maintain continuous coverage.
During a debate last week, Bacon said that was done in an effort to hold people accountable and prevent them from gaming the system by refusing coverage, then jumping back into the pool after they fall ill.
“But if someone wanted to play by the rules, they would be charged the exact same rate as a healthy person,” Bacon said.
[Read more: 2018 election guide]
But Pollitz noted that the ACA has its own mechanism aimed at keeping people accountable — a mandate that everyone in the country maintain health insurance coverage or pay a penalty. Through their tax bill, Republicans eliminated that penalty starting in 2019.
And the Republican health care bill had no penalty for healthy people who refuse to get coverage, thereby providing incentive for that kind of behavior, Pollitz said.
On another front, Nebraska and a number of other states have sued to overturn the rest of ACA now that the individual mandate penalty is going away. If that suit is successful, it could mean the elimination of pre-existing condition protections.
The Republican health care bill also had provisions that would have let states obtain waivers from some ACA requirements if they came up with new ideas for tackling health care.
On Monday, the Trump administration released new rules making it easier for states to allow skimpier health insurance plans — a move it said was all about giving states flexibility to bring down premiums but which experts say would chip away at Affordable Care Act protections for those with pre-existing conditions.
The Congressional Budget Office has previously found that state waivers from ACA protections would most likely lead to increased premiums for those with pre-existing conditions.
Pollitz said, “If states would waive community rating, we could go back to the day when young and healthy people would be offered affordable coverage but people who have a pre-existing condition would have their premium surcharge so high that they wouldn’t be able to afford to get in.”
Bacon said those state waivers were intended to foster innovation. States could obtain a waiver only if they come up with ways to protect those with pre-existing conditions, he said.
It’s true that states would have needed to take steps to protect those individuals in order to get the waiver, Pollitz said, but there’s no guarantee that what they come up with would go far enough.
“Writing it and making it true are not the same thing,” she said.
States could say, for example, that they were addressing those with pre-existing conditions by creating new high-risk pools. But such pools can be expensive.
“We have a lot of history with state high-risk pools, and they never covered but a tiny fraction of the people who needed help with pre-existing conditions,” Pollitz said.