As politicians debate the topic of ensuring that Americans can get insurance coverage for pre-existing medical conditions, there is one critical thing to understand: protecting coverage for people with such conditions is not accomplished by just one part of the Affordable Care Act—it’s achieved through a number of intertwined portions of the ACA.

Understanding how the interlocking pieces of the ACA work together to guarantee coverage for people with pre-existing health conditions is very important because many of the law’s opponents are making vague and unsubstantiated promises that they will restore coverage of pre-existing health conditions if Congress repeals the law or a court strikes it down. However, the ACA’s detractors rarely spell out how they will maintain or restore the law’s consumer protections.

Typically when ACA opponents do offer specific plans for coverage of pre-existing conditions, they propose one narrow solution—requiring that insurers cover people with such conditions—without the interlocking pieces of the ACA that are also necessary. Those pieces include:

• requiring that health plans actually cover essential health care services;
• prohibiting insurers from imposing annual or lifetime caps on benefits;
• facilitating the operation of a subsidized individual insurance market that has enough participants to be able to offer quality, affordable insurance plans; and
• applying federal consumer protections to employer-sponsored insurance plans that are exempt from state regulation.

Simply requiring insurers to offer some sort of coverage to people with pre-existing medical conditions is like trying to protect your home from flooding by using one sandbag, when a wall of sandbags is needed.

A bill introduced in August by ten Republicans in the U.S. Senate illustrates the problem with the simplistic solution that many ACA opponents seem to support. That bill purports to address concerns about the potential loss of ACA protections for people with pre-existing medical conditions, but it misses the mark in a number of respects. One of the problems with their proposal is summed up in this critique by Larry Levit, the senior vice president for health reform at the Kaiser Family Foundation:

“An insurer would have to give you insurance if you have a pre-existing condition, but it could exclude any services associated with your pre-existing condition. This would make protections for people with pre-existing conditions a bit of a mirage.”

If that proposal or others like it become the fallback plan, someone in Wisconsin who has diabetes could find that their insurance plan doesn’t cover their treatment.  Or someone with cancer could find they will no longer be able to afford the life-saving treatment they are getting because after just a couple months they have reached the cap on their coverage.

Thinking carefully about how to cover people with pre-existing conditions is extremely important. It’s estimated that more than 100 million Americans have one or more existing medical conditions, and the current ACA protections for the coverage of those conditions is under assault on many fronts: in Congress, in federal administrative rules and guidelines, and in the courts. For example, Wisconsin’s Attorney general, with approval of Governor Walker, is playing a leading role in a lawsuit challenging the validity of the ACA’s consumer protections.

Governor Walker announced in September that if a court strikes down the ACA, he will call a special session to take up a bill to require coverage of pre-existing conditions. The Governor has not said specifically what that legislation would do, but he appears to be referring to a bill that he endorsed early this year, AB 365. Unfortunately, that proposal is riddled with loopholes.

AB 365 was approved by the Wisconsin Assembly in the summer of 2017, but it was never voted on in the Senate. Like the bill introduced in Congress in August, a basic problem with AB 365 is that it does not include the other protections necessary to guarantee real, affordable coverage of pre-existing conditions. For example, the version of the bill passed by the Assembly would not require insurers to cover essential health benefits and would not preclude them from putting caps on the benefits they provide.

There is also another substantial problem with this sort of state-level legislation. As I wrote in a blog post after the Assembly approved AB 365, one fundamental problem is that federal law precludes states from imposing requirements on employers who self-insure, and those corporations account for most employer-sponsored health insurance coverage in Wisconsin. As a result, if the ACA’s consumer protections are ended by Congress or the courts, we could return to a time when many employer-sponsored plans impose waiting periods of a year or more for coverage of any pre-existing conditions.

Opponents of the ACA haven’t merely failed to propose alternative plans that would adequately replace the law’s consumer protections. They have also failed to speak out against a barrage of rule changes that are undercutting those protections. For example, the Trump administration recently finalized a rule that vastly expands the definition of short-term health plans, which are exempt from the current consumer protections. Wisconsin could remedy that by putting its own limits on the definition of short-term plans, but the Governor and other ACA opponents in Wisconsin have yet to show any inclination to do so.

There has been a good political discussion this fall about the importance of guaranteeing the coverage of existing medical conditions, but the promises by ACA opponents to protect that ACA accomplishment have been sorely lacking in detail. I doubt that their vague promises to protect coverage of pre-existing conditions will translate to effective policy proposals, but I hope I’m wrong.

Regardless of what happens in Wisconsin elections next week, the ACA’s consumer protections will continue to be under assault from the Trump administration, and health care consumers and advocates will have to work hard to achieve a broader public understanding of what it takes to ensure that people can obtain and afford the health care they need.

Jon Peacock