With health care fights dominating the first eight months of Donald Trump's presidency (not to mention the previous eight years since President Obama started work on the Affordable Care Act, aka Obamacare), we're subjected to repeated claims that everyone else is lying, that so-called experts are all self-interested hacks, and promises made won't be fulfilled. So let me be clear: Republicans are lying about what their health care plan will do. Senator Bill Cassidy (R-LA), a licensed doctor, seems to be claiming expertise while acting like a self-interested hack. The promises they have made will not be fulfilled. No matter what they say, Graham-Cassidy does not protect against pre-existing conditions.
The Graham-Cassidy bill technically keeps the Affordable Care Act regulation that forbids insurance companies from denying patients care on account of their medical history. However, it gives states the option of removing the regulation that makes insurance cost the same for everyone, regardless of health status. In effect, that would be very bad for people with pre-existing conditions — since covering sick people is expensive, insurance companies would be incentivized to charge exorbitantly high prices for coverage. Practically speaking, unless they are wealthy enough to pay those insane prices, people with pre-existing conditions would be unable to buy health insurance.
But for some reason, that's not how the bill's advocates refer to the whole thing. Senator Cassidy, his co-sponsor Lindsey Graham (R-SC), and the president of the United States have all brazenly claimed that Graham-Cassidy protects pre-existing conditions, which, I really must emphasize, it does not.
The last time Republicans tried to pass a health care bill, they disagreed with experts like the Congressional Budget Office (as well as health care non-profits, academics, hospitals, doctors, patient groups, and insurance companies) about how the bill would affect the health care system. But this isn't a question of analysis or of which experts you trust, or assumptions about how the health care system works. It's a question of reading comprehension.
You can read the Graham-Cassidy health bill on Bill Cassidy's Senate website (look out! PDF!). If you scroll down to page 12, you can see language allowing states to waive certain regulations, and a list of Affordable Care Act regulations that can be waived. The very first one is as follows:
(I) Any provision that restricts the criteria which a health insurance issuer may use to vary premium rates for health insurance coverage offered in the individual or small group market, or the degree to which an issuer may vary such rates, except that a health insurance issuer may not vary premium rates based on an individual’s sex or membership in a protected class under the Constitution of the United States.
Yeah, it's legalese, but it's clear what that means. A state can waive the rules on health care pricing to allow health insurers to price discriminate for any reason except sex and protected class. That means age, and whether you've been sick before. Raising prices based on pre-existing conditions would be allowed.
I wanted to make sure I got this right, that I understood correctly what this language meant, as I'm not a health care expert myself. So I called one. I spoke with Karen Pollitz, a senior fellow at the nonpartisan Kaiser Family Foundation, one of the country's most prestigious health care think tanks, and a veteran of the Department of Health and Human Services and the Georgetown University Health Policy Institute. She was just as confused by the misleading claims of the bill's proponents as I was.
"Right now there is no language that anyone would point to — a lawyer, or CBO, or anybody else — and say that that is a guarantee that some level of pre-ex protections has to be maintained," Pollitz tells Bustle. "It is simply not there."
The language of the bill does require states to provide "A description of any waiver of the provisions... that the State is requesting, and how the State intends to maintain access to adequate and affordable health insurance coverage for individuals with pre-existing conditions if such waiver is approved." But notably, it doesn't specify anything about what standard has to be met for the waiver to be approved. According this language, a state can respond to the question of how it will protect pre-existing conditions by saying, "We won't," and still have its waiver go through.
Pollitz went on to point to some of the other parts of the section on waivers that make the worries about pre-existing conditions even worse. The bill allows states to waive "any provision that prevents a health insurance issuer offering a coverage plan in the individual or small group market from requiring an individual to pay a premium or contribution (as a condition of enrollment or continued enrollment under the plan)." Pollitz pointed out that, with the wording "continued enrollment," the bill seems to give the go-ahead to let insurers increase prices on patients after they get sick, but once they've already bought health insurance, if states pass a rule on it.
If the bill passes, none of these changes would go into effect immediately, or necessarily go into effect at all. The bill just gives states the ability to make these changes, and exerts pretty close to no rules from the federal government stopping them. At the same time, it constrains health care funding and eliminates the individual mandate, meaning that states would be forced to make tough decisions about how to keep their systems in place, or even how to overhaul them entirely.
Chances are, if you live in states that enthusiastically adopted the Affordable Care Act, like California, New York, or Massachusetts (which actually had a similar system already in place beforehand), you may not lose protections for pre-existing conditions (though with health funding being heavily cut from those states, chances are you will pay more for health care). But in states that have rejected portions of the Affordable Care Act and not sought to expand coverage, we could certainly see a return of problems with pre-existing conditions.
But while it is true that many states would likely protect pre-existing conditions and there is no guarantee that any state would gut protections, it is undeniably false to say that the bill protects them.
If I were to make this assertion based on this bill, for example, I'd be rebuked for publishing false information without doing my due diligence in trying to get things right (though the Bustle editors are quite nice, and possibly forgiving if I were to grovel and make amends).
There have been a lot of ink spilled lamenting how President Trump has assaulted the concept of truth since becoming president. But seeing him, as well as senators who should know better, not go through the simple diligence of reading a bill or talking to an expert that I do is nevertheless infuriating. It's been eight months and one day since Trump was inaugurated. The feeling hasn't gone away.