obamacare affordable care act
Credit: iStock

Trumpcare is back. After a month of sputtering attempts to reboot the effort to repeal and replace Obamacare, leaders of the House Republicans’ moderate and conservative wings are reportedly coalescing around a deal. And yet again, the crux of the deal revolves around sticking it to the sick.

The latest deal, struck by House Freedom Caucus chairman Mark Meadows (R-NC) and co-chairman of the moderate Tuesday Group Tom MacArthur (R-NJ), would allow states to opt out of a key Obamacare protection for people with preexisting conditions. Before Obamacare, insurance companies could charge the sick sky-high, unaffordable premiums, or just deny them coverage outright. Now, insurers are prohibited from jacking up prices on people with pre-existing conditions, and must offer them coverage at the same rates as everyone else (what’s known as “community rating”).

The emerging deal in the House would let states scrap that requirement. This would send insurance premiums soaring for sick people. Someone with lung cancer could pay $73,000 more each year on the free market. A woman with breast cancer could face a sudden $28,000 premium hike. In fact, a woman could get hit with $17,000 in new insurance costs just for getting pregnant.

This leaves the sick with insurance access in name only. Because sick people would be priced out of private markets, the House Republicans would require states that opt out of community rating to offer coverage through high-risk pools.

High-risk pools are separate insurance programs that pull expensive sick people out of general insurance pools in order to lower premiums for everyone else. “Let’s fund risk pools at the state level to subsidize their coverage, so that they can get affordable coverage,” Speaker Paul Ryan once proposed. “You dramatically lower the price for everybody else.”

This applies the logic of leper colonies to health insurance: quarantine the sick to benefit the healthy. And like other quarantines, high-risk pools have been hellish experiences for the afflicted. Before Obamacare, 35 states had tried high-risk pools to provide coverage to people deemed “uninsurable” on the private market. Enrollees on these pools paid exorbitant premiums for minimal coverage. Premiums ran in excess of double those paid by healthy individuals. In some states, deductibles were as high as $25,000 while annual coverage limits were as low as $75,000. Worse, most high-risk pools excluded coverage for preexisting conditions for up to a year—making the coverage virtually useless to someone with a serious condition.

Even still, high-risk pools could only be sustained with massive injections of government money. Yet because they were chronically underfunded, high-risk pools only managed to cover a small fraction of the uninsured population.

High-risk pools also import one of the conservative nightmares of socialized medicine: long waiting lists. In the 1990s, thousands of people languished waiting for coverage on high-risk pools in states like California. “People would literally pass away while they were on the waiting list,” said Richard Figueroa, a former administration of California’s high-risk pool.

That’s the trash-heap policy that some Republicans would now like to dust off to replace Obamacare. And their case for high-risk pools relies on muddying the waters over how Obamacare—and health insurance itself—fundamentally works.

If we had a single-payer system, everyone would pay taxes to the government for healthcare instead of paying insurance premiums. And when we pay taxes, we implicitly understand that our money goes to pay for services benefiting others. So under single payer, the taxes paid by the healthy would help pay for healthcare for the sick. Indeed, that’s how coverage in any one given health insurance plan works—single-payer would just put everyone under the same plan.

Instead of enacting a single-payer system, Obamacare grafted near-universal healthcare on to a private insurance system. Everyone is required to purchase insurance, and the healthy and sick must pay the same rates. So rather than subsidizing the sick through taxes, the healthy pay for the healthcare of the sick through their private insurance premiums.

But because we buy our own coverage on private markets, health insurance still feels like an individual product instead of a social one. My premiums shouldn’t rise just because someone else has huge expenses, the thinking goes. And that’s the sensibility that conservatives appeal to when they argue for high-risk pools. “There is a better way to fix that problem [of coverage for people with pre-existing conditions] without giving everybody else all of these massive premium increases,” Ryan has said.

But that thinking denies the fact that we’ll be paying for the costs of the sick one way or another, whether through our insurance premiums or the taxes to fund high-risk pools. More fundamentally, it chips away at the core ethic of universal healthcare: that a decent society has a moral obligation to ensure that the sick can obtain healthcare. If history is any guide, high-risk pools fall far short of this ethic, shunting the sick into expensive yet poorly funded programs with bad coverage and long waiting periods.

Republicans are trying to jumpstart failed Trumpcare by latching on to failed high-risk pools. But much like the original Trumpcare, the new deal emerging in Congress is an awful deal for the sick. For both the country as a whole, and those who need healthcare the most, any deal that harms the sick is a massive step backward.

Joel Dodge

Joel Dodge is a writer and attorney in New York City. His work has appeared in Quartz, The Week, The New Republic, and The American Constitution Society.