PRE-EXISTING PROBLEM — If there’s one thing Republicans learned in their prolonged but politically costly failed attempt to repeal the Affordable Care Act, it’s that protecting people with pre-existing conditions is pretty darn popular across the red-blue spectrum. In fact, it’s so popular that even a narrow majority of Republicans support it, even though they are still negative about the ACA overall, according to a February KKF poll , one of the very few surveys that even bother asking about pre-ex anymore. But JD Vance just went there. Twice, at least, this week alone. Donald Trump’s running mate might have turned the presidential race into a health care election after all. “It’s been very consistent that it is popular — across regions, ideology, party and other factors — that people should not be denied or discriminated on based on pre-existing conditions,” Anthony Wright, the new executive director of the health advocacy group Families USA told Nightly. “It’s bizarre to be reopening this, but here we are.” Vance on Meet the Press last Sunday and in Raleigh on Wednesday, outlined a plan to “deregulate” health care while somehow still making sure everyone had coverage, including the tens of millions of Americans with pre-existing conditions. “You also want to implement some deregulatory agenda so that people can choose a health care plan that fits them,” he said. “And we want to make sure everybody is covered. “But the best way to do that is to actually promote some more choice in our health care system and not have a one-size-fits-all approach that puts a lot of people into the same insurance pools, into the same risk pools, that actually makes it harder for people to make the right choices for their families,” Vance added. There’s an awful lot that isn’t spelled out in those remarks, including whether health plans would still have to offer everyone the same basic benefits or how much premiums could vary from young and healthy to old and sick. It’s not even clear how Vance’s comments hew to the “concept of a plan” former president Donald Trump has for changing the ACA; Vance has walked-back predictions about what Trump would or would not do before, notably regarding a national abortion ban. But putting sick and healthy people in separate “risk pools” or different segments of the insurance markets is widely seen as a recipe for jacking up the cost of coverage for people who have pre-existing health conditions and need a lot of medical care. The Kamala Harris campaign, which has been focused on reproductive health but less on cost and coverage, wasted no time in accusing the GOP ticket of “Ripping Away Protections for Pre-Existing Conditions.” But Vance hasn’t backed off. “We’re going to actually implement some regulatory reform in the health care system that allows people to choose a health care plan that works for them,” he told a reporter after his rally in Raleigh Wednesday . “What that will also do is allow people with similar health situations to be in the same risk pools.” He said that would “work better” for people with chronic health problems and for “everybody else.” But splitting the insurance market into healthy and sick people doesn’t work (unless you give the sick super, super high subsidies). That’s not a political assessment; it’s an actuarial fact of life. Just ask an actuary . Before the ACA, people with pre-existing conditions were often denied coverage flat out If they tried to buy a policy on the individual market. Or they were offered insurance at sky-high prices. (People who got covered through an employer were generally protected). States, blue and red, that tried putting people with pre-existing conditions into high risk pools before Obamacare found they didn’t work very well . The same applies to the version of risk pools the House GOP considered as part of the repeal and replace plan in 2017 — which sounds similar to what Vance is sketching out right now. When premiums soar, fewer people get covered, and premiums soar even more — it’s referred to in the health insurance market as a “death spiral.” Pre-existing conditions are common. Very common. According to the Centers for Disease Control, “about 129 million people in the U.S. have at least one major chronic disease such as, heart disease, cancer, diabetes, obesity, hypertension.” Millions more have other chronic conditions like asthma, kidney disease, respiratory ailments, depression and other mental health conditions. Before the ACA, insurers could just not offer coverage to chronically ill people. Under the ACA, they have to cover everyone. But under a deregulated version of the ACA, insurers might be obligated to offer coverage to sick people — but they wouldn’t have to make it affordable. How much the ACA stays on the 2024 table in the remaining weeks of the campaign is uncertain. So far, apart from the intense attention to reproductive health and some discussion of drug prices, health care has probably gotten less campaign oxygen than in any election cycle in a quarter century or longer. Going into November, as some Republicans have themselves acknowledged, the Affordable Care Act is far more popular, and far more entrenched in U.S. health care, than in past elections. Aside from Republicans, more than half of independents and overwhelming numbers of Democrats back it, according to that KFF poll. As former President Barack Obama joked at the Democratic convention last month, “I’d noticed, by the way, that since it’s become popular, they don’t call it Obamacare no more.” Welcome to POLITICO Nightly. Reach out with news, tips and ideas at nightly@politico.com . Or contact tonight’s author on X (formerly known as Twitter) at @JoanneKenen .
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