Editorials of The Times

Posted October 31, 2018 11:50 p.m. EDT

A Voter’s Guide to Health Care

“I support forcing insurance companies to cover all pre-existing conditions,” Josh Hawley, the Republican attorney general of Missouri who’s running for the Senate against Claire McCaskill, assured voters in an emotional ad featuring his son, a kindergartner who suffers from such a condition.

It’s a promise Hawley has repeated again and again on the campaign trail this fall, and it’s a popular one — national poll results released in September found that three-quarters of Americans want to retain protections that prevent insurers from discriminating against people based on their medical history.

Yet, while Josh Hawley the candidate might be a fan of saving such protections, Josh Hawley the attorney general plainly isn’t — he’s one of 20 Republican state attorneys general suing to overturn the Affordable Care Act and abolish the pre-existing condition protections that go with it.

Health care is routinely cited by voters as their top issue as they head to the polls next Tuesday, and rightly so — the midterms could help decide whether many Americans will have access to care and how much it will cost. Hawley is only one of many candidates on both sides of the aisle eager to convince them that he’s in their corner.

Given that interest, it’s worth clarifying the record on these issues so voters are informed heading into the polls. Will Republicans try to repeal the Affordable Care Act again? Will Democrats push hard toward a single-payer system — and, if so, what will that mean for employer-based insurance and Medicare as we know it? And which party will be more likely to protect Americans with pre-existing medical conditions from insurance discrimination?

— Obamacare

After failing to repeal the Affordable Care Act in 2017, congressional Republicans went on to undermine the law in crucial ways. They eliminated the individual mandate, which required most people either to have insurance or to pay a small tax penalty. They allowed more non-ACA plans — cheaper, skimpier options that don’t have to cover pre-existing conditions or provide essential benefits — into the marketplace. And they scrapped federal subsidies that compensated insurance companies for offering lower premiums to Americans earning between 100 percent and 250 percent of the federal poverty level.

These and other maneuvers have destabilized the insurance market and created confusion among both insurers and citizens. Bipartisan efforts to address these problems have fallen victim to politics.

At the same time, Republican state attorneys general, like Hawley, are seeking to repeal the ACA entirely. Most legal experts agree that their lawsuit is a long shot, but that won’t necessarily stop Republicans from pursuing other avenues to repeal. On Oct. 17, the Senate majority leader, Mitch McConnell, floated the idea of mounting another campaign to overturn the law, should the Republicans hold on to both chambers of Congress. As Morning Consult noted, the move was most likely meant to rally Republican voters, most of whom still want to repeal the law despite the growing popularity of protections for people with pre-existing conditions.

If Democrats win at least one chamber of Congress, Obamacare as it stands now is probably safe, although it’s unlikely to see the fixes and improvements that such a far-reaching government initiative requires. If Republicans prevail, all bets are off.

— Medicare-for-All

As health care costs rise, more Americans are voicing support for a single-payer system: Fifty-three percent now support such a plan, compared with less than 40 percent in the early 2000s. Both parties have noted the trend. Republicans are scared enough by the prospect that President Donald Trump wrote a scathing and wildly inaccurate op-ed in USA Today, denouncing the concept.

Democrats, for their part, advocate a range of single-payer options that include true Medicare-for-All — which would expand the existing government program to cover everyone — and a “public option” that would allow people to opt in to Medicare. So far, details on each are fuzzy; it remains to be seen how various such proposals would grapple with costs, consumer choice and doctor pay. Vermont’s single-payer experiment, for instance, largely failed because it ran out of money. But if Democrats take the House, expect to see a lot of pressure from the progressive end of the party to introduce legislation. Only then will we see how single-payer might actually play out, and by 2020, whether voters are truly willing to go down that path.

— Pre-existing Condition Protections

Republicans have long insisted they want to protect people with pre-existing conditions from insurance discrimination — just not through the Affordable Care Act. This is not, by itself, an indefensible position. The current law provides ironclad protections to people with serious medical conditions, but it also has forced a lot of the burden of that coverage onto the shoulders of middle-income Americans who earn too much to qualify for the law’s subsidies and whose premiums and deductibles are soaring.

But it’s tough to argue that one is for pre-existing condition protections when one is actively fighting the only federal law to ever have guaranteed those protections in the first place. There may well be a better way to prevent insurance companies from discriminating against the sick — one that doesn’t price middle-class Americans out of the market. But so far, Republicans have not found it.

One of their more recent proposals would require insurers to cover people with pre-existing conditions but would allow the insurers to exclude coverage of the condition itself — so it would be possible for a given person to be covered, even while their cancer relapse is not. Other suggestions include having the federal government pick up the tab for pre-existing condition coverage. But so far, those offerings range from vague to inadequate.

Far more concrete are the many ways that Republicans have sought to undermine pre-existing condition protections over the past two years, including by trying to overturn the Affordable Care Act itself.

— Prescription Drug Costs

Trump took office on a promise to dramatically lower the cost of prescription medicine. Since then, Trump and Congress have made only minimal progress on this goal. They’ve abolished gag rules that prohibit pharmacists from advising customers on how to pay less for prescriptions, and cracked down on drug companies that try to block cheaper, generic versions of their product from making it to market. But neither of those measures, nor any of the others Trump has proposed as the election draws near, are likely to make much of a dent in what average consumers pay at the pharmacy counter.

Most experts agree that to truly lower drug costs, the federal government — that is, Medicare and Medicaid — will have to negotiate directly with drugmakers. This is what other countries do, and it’s why their citizens all pay far less than Americans for the same medications. Trump campaigned on this idea, and Democrats have been pushing it for years. But so far, Americans have shown little appetite for the trade-offs this approach would require. Successful negotiations would require a willingness to forgo coverage of certain medications — namely, those whose costs outweigh their benefits.

It does not help that there are more pharmaceutical lobbyists than lawmakers on Capitol Hill. Those lobbyists give generously to both political parties. And this year, with more than $21 million spent, they are on track to break their own spending record.

Democrats are promising to finally hold the industry’s feet to the fire if they take the House. Their track record is certainly better than Republicans’ on that front, but given that the problems of prescription drug pricing predate the Republican takeover of Congress — by many years — it’s right to be skeptical.

— Medicaid Expansion

So far, 34 states have chosen to opt in to the Affordable Care Act’s Medicaid expansion program, which provides coverage for working-age adults who earn up to 138 percent of the federal poverty line. On Tuesday, three more states — Idaho, Nebraska and Utah — will decide whether to join those ranks, and several others — including Florida, Georgia, Wisconsin and Maine — will decide whether to replace a Republican governor who has opposed Medicaid expansion with a Democratic one who supports it.

Republican officials have opposed Medicaid expansion for the same reason they’ve opposed most large social safety-net programs: It’s expensive. The federal government pays 90 percent of expansion costs, but even so, states have spent more than expected on the program. Trump has changed the rules to allow individual states to attach work requirements to Medicaid coverage, and has proposed turning the program into a block grant (the federal government would give each state a fixed amount of money, rather than paying a percentage of the total cost).

But while Medicaid expansion isn’t cheap, it has produced substantial benefits, among them expanded access to health care, improved financial security for low-income families and economic gains for the health care industry.

In any case, sweeping changes to the program are likely to prove tough: Medicaid is increasingly popular among voters, in part because so many of them — roughly 1 in 5 Americans, as of June — now receive benefits through the program.

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