During Tuesday night’s vice presidential debate, Republican candidate Sen. J.D. Vance of Ohio vowed to protect health insurance coverage for people with pre-existing conditions while also strengthening proposals to place them in so-called high-risk groups. , separating them from healthier people.
To many policy experts watching the debate, the two statements seemed contradictory and harkened back to the days before the Affordable Care Act, which guaranteed coverage for people with pre-existing conditions. It was.
“We’ve tried that in the past and failed,” said Arthur Caplan, director of medical ethics at New York University Langone Medical Center in New York City. “Anything that separates itself from the existing situation is doomed to complete failure.”
Until the passage of the ACA in 2010, most states relied on high-risk pools to provide coverage to individuals with chronic conditions, said Dr. said Cynthia Cox, ACA Program Director. . The high-risk pool is people who don’t have cancer or diabetes but fall into the “gray zone” category, where their child has had three ear infections in the past year, potentially increasing their insurance premiums. It was also used. Cox said.
According to Cox, patients with serious illnesses such as cancer and chronic diseases in Japan account for only about 5% of the population, but account for more than half of all medical expenses. Because of the prohibitive costs, insurance companies often deem chronically ill people “uninsurable” and deny coverage, she said.
“The treatment was very expensive and I couldn’t get insurance anywhere,” Cox said.
The idea behind high-risk pools was to provide a safety net for people with pre-existing conditions who struggle to find insurance. This pool of people with chronic illnesses often combines state funds, mandates, and federal subsidies to encourage insurance companies to offer coverage by eliminating some of the economic risk. did. This also helped keep monthly premiums low for sick patients.
But high-risk pools are severely underfunded, with monthly premiums for some patients double those of healthy people, Cox said. Due to lack of funds, insurance companies will also refuse to cover the patient’s treatment.
“If you fall into a high-risk group, you may be excluded from insurance coverage for six to 12 months,” Cox said. “So, for example, if you’ve just been diagnosed with cancer, you may not be able to receive chemotherapy for six months or a year after you’re in a high-risk group.”
The ACA addressed this problem by eliminating high-risk pools in favor of a single-risk pool model, where younger, healthier people help offset the costs of older people, who typically have more chronic conditions. I tried to deal with it.
“The underlying idea is a kind of social contract,” says John A. Graves, a professor of health policy and medicine at Vanderbilt University School of Medicine in Nashville, Tennessee. “When you’re healthy and young, you pay the same monthly premiums, but if one day you get sick or incur high costs, that market will continue to support you.”
Minnesota Governor Tim Walz, the Democratic vice presidential candidate, expressed similar views during the debate.
“I think the idea of having a large enough risk pool to cover everyone is the only way insurance can work,” Walz said. “Otherwise it will collapse.”
Graves said the U.S. could return to a high-risk pool model, but that would require “huge government subsidies to make it work.”
“Basically, we’re going to need to inject enough subsidies into high-risk populations to keep premiums affordable for people,” he said. “If we don’t, functionally speaking, we’ll be raising premiums for sick people.”
For Cox, the benefits of returning to a high-risk model were unclear, especially if the federal government would have to provide more money to fund the program.
Caplan said that still wouldn’t work.
“To make it affordable, the risk needs to be shared widely across a large group,” Caplan said. “For the past 25 years, we’ve been segregating existing pools and it hasn’t worked.”
