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WASHINGTON — President Donald Trump and congressional Republicans, despite repeated pledges to preserve sick Americans’ access to health coverage, are poised to scrap this core insurance protection in their campaign to roll back the Affordable Care Act.
The House GOP bill that passed in May and the revised Senate GOP bill announced last week would effectively eliminate the coverage guarantee by allowing health insurers to once again sell skimpier plans and charge more to people with preexisting health conditions who need more-comprehensive coverage.
At the same time, the House and Senate bills would significantly scale back financial aid to low- and moderate-income consumers, and slash funding for Medicaid, the government safety-net plan that has helped millions of sick and poor Americans gain coverage.
That combination — looser insurance requirements and less financial assistance for patients — would once again put health plans out of reach for millions of sick Americans, according to numerous analyses.
“The fundamental guarantee at the heart of the Affordable Care Act was that people who are sick can get insurance at the same price as everyone else,” said Larry Levitt, an insurance market expert at the nonprofit Kaiser Family Foundation. “The House and Senate replacement bills move the system back to a place where healthy and sick people are treated very differently.”
The Senate is slated to begin voting on its health care bill this week.
The Affordable Care Act’s coverage guarantee remains among the most popular parts of the 2010 law, with nearly 7 in 10 Americans rating it favorably.
Trump administration officials and GOP congressional leaders insist the Republican bills won’t leave anyone behind.
“The legislation ensures that every American with pre-existing conditions has access to the coverage and care they need, no exceptions,” Vice President Mike Pence told a meeting of the National Governors Association in Rhode Island Friday.
But that assurance has been contradicted by nearly every independent evaluation of the Republican health care bills, including two lengthy reports by the nonpartisan Congressional Budget Office.
Pence’s claims are also at odds of with the assessment of health insurers themselves.
On Friday, the heads of the industry’s two leading advocacy groups — America’s Health Insurance Plans and the Blue Cross Blue Shield Association — called the Senate bill “simply unworkable,” warning it “would undermine protections for those with pre-existing medical conditions.”
Similarly, in a letter to Senate leaders this month, the American Academy of Actuaries warned that provisions of the Senate GOP bill “could erode pre-existing condition protections” and “make it more difficult for high-cost individuals and groups to obtain coverage.”
Nearly every major patient advocacy organization has reached the same conclusion.
“Older and sicker individuals … would face the full cost of these higher premiums, leaving millions of people with chronic conditions and disabilities unable to afford the kind of coverage they need,” a coalition of 13 patient groups wrote in a letter to senators last week, condemning the latest version of the Senate bill.
The coalition includes the American Heart Association, the American Lung Association, the March of Dimes, the Cystic Fibrosis Foundation, the AARP and the advocacy arm of the American Cancer Society.
The kind of deregulated insurance markets envisioned by the House and Senate bills would mark a return to what health insurance looked like before the current health care law was enacted in 2010.
Before the Affordable Care Act, most insurance companies worked aggressively to exclude sick customers, either denying coverage altogether or charging unaffordable prices to people with pre-existing conditions such as cancer, diabetes, even acne.
That left tens of millions of Americans with next to no options for coverage.
Although some states offered special health plans for sick patients who’d been rejected by insurers, most of these so-called high-risk pools limited benefits or capped enrollment because the coverage was so costly.
“It was a medical gulag,” said Richard Figueroa, former enrollment director of California’s plan, which had a long waiting list because demand always outstripped money available for coverage.
The Affordable Care Act fundamentally equalized how health insurance treats patients. Insurers were not only forbidden to deny coverage to sick consumers, they also had to provide a basic set of benefits.
That standardization ensured that sick Americans were not forced to pay more for health insurance than healthy Americans, who might be tempted to buy skimpier plans that did not offer some benefits, such as prescription drugs or mental health and substance-abuse therapy.
This meant higher costs for some consumers, particularly those who enjoyed lower premiums before the law, when insurers were allowed to exclude the sick.
But uniform standards are necessary to ensure equal access to coverage, said Manatt Health managing director Joel Ario, a former insurance commissioner in Oregon and Pennsylvania. “It doesn’t work unless everyone participates on the same terms.”
To date, more than 20 million Americans have gained coverage through the law and many more depend on its protections.
Republicans have been careful to emphasize that their legislation to repeal the Affordable Care Act would not eliminate the coverage guarantee that prohibits insurers from denying coverage.
Sen. Bill Cassidy, R-La., famously pledged that he wouldn’t vote for a bill that didn’t pass what he called the “Jimmy Kimmel test,” in a reference to the late-night host’s emotional explanation of how important it had been that his baby son was not shut out of insurance coverage after being born with congenital heart disease.
“We think it’s great to give people more options and more choices and the freedom to actually buy the insurance products they want,” said Sen. John Thune of South Dakota, the third-ranking Republican.
Conservative Republicans led by Texas Sen. Ted Cruz, who insists on the insurance deregulation, have said they will not support the Affordable Care Act repeal bill without Cruz’s amendment.
But offering this kind of “choice” — even with additional money to help sick consumers — would effectively end the coverage guarantee, the two health insurance groups said.
“Given our experience and long-standing commitment to providing health care coverage, we understand what it takes to make health insurance markets work for consumers,” the presidents of the groups wrote.
“We believe strongly that the rules must apply equally to all insurance.”