In the weeks before Tuesday’s vice-presidential debate, Senator JD Vance sounded like someone who wanted to repeal the Affordable Care Act.
Mr. Vance, discussing how he would reform the 2010 health law, said he favored separating healthy and sick Americans into their own health insurance groups, an idea Republicans proposed in 2017 when they attempted to reverse the law.
But when pressed during the debate to explain how that would work, Mr. Vance appeared to back away from the idea, which health policy experts have said could significantly disrupt many Americans’ insurance coverage.
“We currently have laws and regulations in place, in place right now, that protect people with pre-existing conditions,” he said on Tuesday. “We want to keep those regulations in place, but we also want to make the health insurance marketplace function a little bit better.”
His shifting position was similar to that of his running mate, former President Donald J. Trump, who had also called for major overhauls to the Affordable Care Act in recent months before retreating. Mr. Vance’s comments also reflected the complicated politics of Obamacare for Republicans, who have largely given up broader attempts to eliminate the Affordable Care Act as it has grown in popularity and had record enrollment in its marketplaces.
The “laws and regulations” Mr. Vance referenced come directly from the Affordable Care Act, which required insurers to sell health coverage at a standard price to any American who wanted to buy a plan, regardless of age, sex or health history.
The law reversed a long history of insurance gaps in which healthier Americans could buy insurance, while those with a history of cancer, diabetes or even asthma were often limited to small, expensive and restricted health insurance groups run by states, or “high risk pools” if they could not get health coverage at work.
Ahead of Tuesday’s debate, Mr. Vance seemed to call for a return to such a system.
“We want to make sure everybody is covered,” he said during a recent appearance on NBC’s “Meet the Press.” “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.”
Mr. Vance’s comments resurrected the debate over coverage of pre-existing conditions, one of the central, and most popular, provisions of the Affordable Care Act. They also gave Gov. Tim Walz of Minnesota, Vice President Kamala Harris’s running mate, an opening to confront Mr. Vance at the debate.
“The idea of making sure the risk pool is broad enough to cover everyone, that’s the only way insurance works,” Mr. Walz said. “When it doesn’t, it collapses.” He added that “when we incentivize people to be in the market, when we help people who might not be able to afford it get there, and we make sure then when you get sick and old, it’s there for you.”
Ms. Harris’s campaign has used Mr. Vance’s comments on separating Americans into health insurance groups to focus attention on the Affordable Care Act this week.
Her campaign released a report on Monday on the possible consequences of repealing Obamacare and has also been running television ads this week seeking to highlight the issue.
In Mr. Vance’s telling on Tuesday, Mr. Trump rescued the Affordable Care Act when it was “crushing under the weight of its own regulatory burden and health care costs.” Mr. Trump had “preserved people’s access to coverage who had pre-existing conditions,” Mr. Vance said.
In fact, the Trump administration pursued an agenda meant to weaken the health law, including by asking the Supreme Court to invalidate it.
Conservative health policy experts have come to Mr. Vance’s defense. Brian Blase, who served as a White House official under Mr. Trump, said in a recent commentary in The National Review that the Affordable Care Act had led to “an extremely expensive high-risk pool that stays afloat only with massive government subsidies.” He said reforms had led to “inefficient structure” that harms people with low-quality plans and higher premiums.
The likelihood of any major overhauls to the health law in the coming years is unclear, regardless of who wins the presidency.
More sweeping reforms would likely need 60 votes in the Senate, rather than just a simple majority. Meeting that threshold is unlikely given that neither party is expected to gain a significant majority in the House or Senate in November. And top congressional Republicans appear to have little appetite to try to repeal the Affordable Care Act, given that their last attempt was unsuccessful and politically damaging in the 2018 midterm elections.
Before the Affordable Care Act was signed into law, dozens of states offered plans through what were known as high-risk pools. A risk pool refers to a set of health insurance buyers whose premiums are combined to cover the group’s medical needs.
“But they only had so much money to do it,” Coleman Drake, a health economist at the University of Pittsburgh, said, referring to how the pools were subsidized. “So they had to do things like allow high deductibles or prohibitively expensive premiums.”
Those with pre-existing conditions who bought cheaper plans with fewer restrictions could be turned away or kicked out of them. States also incorporated lifetime limits on coverage.
“Insurers don’t like more sick people than they can account for,” Dr. Drake said.
With the Affordable Care Act, lawmakers required insurers to cover a basic set of health benefits and prohibited them from excluding people who wanted to buy plans. They could not charge higher prices to someone based on past health problems, or cap benefits over someone’s lifetime. Instead of separate pools, Obamacare markets put everyone in one area into the same risk pool, then provided income-based financial assistance so people could afford their premiums.
Roughly half of all health spending goes to the 5 percent of the U.S. population with the highest health costs.
Dividing the healthy and sick could lead to vastly different costs for health care for each group, lowering premiums for the healthy while substantially increasing them for those who have a history of health problems.
It is still unclear whether Mr. Vance’s comments on risk pools were part of a broader health care platform. During the presidential debate, Mr. Trump said he had “concepts of a plan” for improving the Affordable Care Act, and that he would soon release a proposal. His campaign has not yet published a health care plan. As a presidential candidate, Mr. Trump has repeatedly made ambiguous assertions about his plans for reforming the Affordable Care Act.
At Tuesday’s debate, Mr. Vance said he had been referring to “reinsurance regulations,” a program that states use to funnel extra money to insurers to offset the costs of the most expensive patients in the Obamacare marketplaces. Mr. Vance may have also been referring to short-term health insurance plans that were not required to cover a comprehensive set of health benefits and could discriminate against Americans with prior illnesses. The Trump administration encouraged their use, while the Biden administration has sought to limit them.
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