during Tuesday night’s vice presidential debateThe Republican candidate, Sen. JD Vance of Ohio, has pledged to protect health insurance coverage for people with pre-existing conditions. Double down on the offer to place them high in a word–risk poolseparates them from healthier individuals.
To many policy experts watching the debate, the two statements seemed irreconcilable — and at one point backfired. Before the Affordable Care ActIt became law to guarantee coverage for people with pre-existing conditions.
“We’ve tried it in the past and it failed,” said Arthur Kaplan, chief of medical ethics at NYU Langone Medical Center in New York. “Anything that separates pre-existing conditions is doomed to total failure.”
Before the transition ACA In 2010, most states relied on high-risk pools to cover people with chronic conditions, said Cynthia Cox, vice president and director of the ACA program at KFF, a nonprofit group that researches health policy issues. High-risk pools were also used for people in the “grey zone” category, where they don’t have cancer or diabetes “but their child had three ear infections in the last year and the insurance could charge them a higher premium.” Cox said.
The country’s sickest patients, such as those with cancer or chronic diseases, make up only 5% of the population. but accounts for more than half of all health care spendingCox said. Because of the exorbitant cost, insurers often consider chronically ill people “uninsurable” and deny them coverage, he said.
“You had such high costs, you just couldn’t get insurance anywhere,” Cox said.
The idea behind the high-risk pool was to provide a safety net for people with pre-existing conditions who had trouble finding coverage. Pools that pooled chronically ill patients encouraged insurers to offer coverage removing part of the financial riskoften through a combination of state funding, mandates, and federal grants. This has also helped keep monthly premiums low for sicker patients.
However, high-risk pools are critically underfunded, making monthly premiums for some patients double what they would be for a healthy person, Cox said. Insurers were also refusing to provide care to patients due to lack of funding.
“If you get into the high-risk pool, you could be out of coverage for six to 12 months,” Cox said. “So if you were just diagnosed with cancer, for example, you wouldn’t be able to get any chemotherapy for six months or a year after entering the high-risk pool.”
The The ACA tried to address this problem by eliminating high-risk pools in favor of a single-risk pool model in which younger, healthier people would typically help cover the costs of older people with more chronic illnesses.
“The basic idea is a kind of social contract,” said 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 when you get sick one day or have higher costs, this market will continue to support you.”
In the debate, the Democratic vice-presidential candidate, Minnesota governor Tim Waltz, had a similar opinion.
“I think the idea of making sure the risk pool is wide enough to cover everybody is the only way to insure,” Walz said. “When it doesn’t, it falls.”
Graves said the U.S. could return to the high-risk pool model, but it would require “huge amounts of government subsidies to make it work.”
“They’re basically going to have to subsidize the high-risk pool enough to keep premiums affordable for people,” he said. “If they don’t, functionally speaking, you increase premiums for sick people.”
According to Cox, the benefits of returning to a high-stakes model were unclear, especially if the federal government would have to allocate more money to fund the program.
Kaplan also said this, it wouldn’t work.
“You have to share the risk widely across a large group to make it affordable,” Kaplan said. “For the last 25 years we’ve isolated pre-existing pools and they don’t work.”