Republicans Say They Will Protect Pre-existing Conditions. Their Records Say Something Else.

In campaign speeches, advertisements and interviews, Republican politicians are showing a zeal for protecting Americans with pre-existing health conditions.

President Donald Trump has gone the furthest, saying not only that he will ensure protections for the previously ill, but also pledging that his party will do so more effectively than Democrats.

There are many reasons to doubt these words.

The recent history of health care politics in the United States suggests that the president has things backward. (My colleagues Peter Baker and Linda Qiu declared the tweet “false” in an assessment of many recent statements by the president.) It is Democrats, by passing the Affordable Care Act in 2010, who introduced meaningful protections for Americans with prior illnesses.

And Republican officeholders have taken numerous actions that would tend to weaken those protections — in Congress, in states and in courts. The Trump administration introduced a sweeping new policy just last week that would allow states to sidestep Obamacare’s requirement to cover pre-existing conditions.

The Republican claims emerge amid growing evidence that health care is a motivating issue for many voters, and that Obamacare’s protections for people with prior illnesses are popular. Pre-existing conditions have been a central theme in Democratic campaigns around the country.

Although it is possible to provide for people with prior illnesses using mechanisms other than Obamacare, few Republican politicians are pointing to any specific plan that would do so. The president certainly isn’t. Given that silence, it is worth comparing politicians’ promises with their records.

Last year, Republicans in Congress led an extended but ultimately unsuccessful effort to, in their words, “repeal and replace” the Affordable Care Act. Although a bill passed through the House of Representatives, Republicans in the Senate were unable to agree on a particular replacement for Obamacare.

The House bill, called the American Health Care Act, had provisions that would have weakened current protections for people with pre-existing illnesses. It would have allowed states to eliminate Obamacare’s rules that health insurance must cover a standard set of benefits, like prescription drugs and mental health care, and its rule that insurance companies must charge the same prices to customers whether they are healthy or sick.

The House bill created a small pool of money for states to help sick customers who might be shut out of such markets. A majority of House Republicans voted for this bill.

Had this bill become law, the precise results would have depended on the choices by individual states. But the Congressional Budget Office estimated that nearly half of all Americans lived in a state that would have pursued such a waiver from standard benefits. The consequences, the CBO said, would have been coverage that was unaffordable to many with pre-existing illnesses, along with holes in coverage for many serious conditions. For example, someone with a substance-abuse disorder might have lived where plans for people with that condition were very expensive and didn’t include addiction treatment.

The Senate considered several bills. A majority of Republican senators supported them all. Two would have included slightly different programs that would have allowed states to sidestep Obamacare protections.

Nearly every Republican incumbent who is now pledging to protect pre-existing conditions supported one of these measures. That’s true of Sen. Ted Cruz of Texas, who once helped to shut down the entire federal government over a demand that Obamacare be reversed. It is also true of Dana Rohrabacher, a congressman from California, and Martha McSally, a congresswoman running for Senate in Arizona.

Trump has said he continues to back repeal efforts. Sen. Mitch McConnell, R-Ky., the majority leader, said recently that Congress would consider such legislation if Republicans retained their control after the election.

Several Republican senators have co-sponsored a bill that would ensure that people with pre-existing illnesses could buy insurance at standard prices if Obamacare were repealed or overturned. But that bill includes a large loophole: Insurers would not have to cover any care related to that condition. That bill is not scheduled for a vote, and the president has not endorsed it.

A federal judge in Texas is expected to rule soon on a court challenge to Obamacare brought by Republican officials in 20 states. The lawsuit argues that the entire Affordable Care Act is unconstitutional and should be overturned. Among the state officials who are bringing the lawsuit are Josh Hawley, the attorney general from Missouri who is running for Senate, and Patrick Morrisey, the attorney general from West Virginia running for Senate there.

In most such lawsuits, the Justice Department defends laws passed by Congress. But the Trump administration has declined to do so. Its position is that most of the law should stand, but that the court should eliminate only the provisions that protect Americans with pre-existing health conditions.

Trump administration officials have repeatedly blamed Obamacare for increases in insurance prices and reduced consumer choice. And they have taken several steps on their own meant to allow people to wiggle around the health law’s rules, including those protecting people with pre-existing conditions.

Just last week, the Centers for Medicare and Medicaid Services, which runs Obamacare programs, announced it would welcome state applications to waive many of Obamacare’s rules for what insurance must cover and how it is funded.

Trump administration officials made clear that they might let states use federal subsidies to pay for health plans that do not cover people with pre-existing conditions. As long as a similar number of people have some sort of health coverage, and a comprehensive option exists for people who want it, states will be allowed to adopt plans that expand skimpy coverage for the well and increase the costs of coverage for those with pre-existing conditions. The recent proposal builds on another recent administration policy allowing insurance companies to offer so-called short-term insurance plans. The plans can exclude many common benefits and deny coverage to people with pre-existing conditions. Short-term plans hit the markets in many states this fall. Because they cover fewer benefits and because sick people can’t buy them, they tend to be cheaper than the more comprehensive policies that must follow Obamacare’s rules.

After years of political losses linked to Obamacare, Democrats are suddenly taking pride in the health law. It established very clear protections for people with pre-existing conditions, in employer insurance, and especially in the individual market for health insurance.

Under Obamacare’s rules, health plans cannot discriminate against customers who have been sick in the past. They can’t charge them higher prices than they would a healthy person in the same place and of the same age. All plans have to cover the same benefits, so it is not possible for a plan to offer coverage to a cancer patient but exclude cancer coverage, as some plans did in the years before the Affordable Care Act.

Those current protections are the legal status quo.