The future of protections for people with pre-existing conditions has once again become a focus of debate following recent legal and policy developments. The Affordable Care Act (ACA) contained a number of new rules related to pre-existing conditions, including: (1) Guaranteed access to insurance in the individual market regardless of health. Previously, insurers typically used medical underwriting to deny coverage to people with pre-existing conditions, and also excluded coverage of any pre-existing conditions for people who were accepted. (2) Community rating in the individual and small business markets, prohibiting insurers from varying premiums based on people's health, which was common before the ACA. (3) Required coverage of essential benefits. Prior to the ACA, insurers in the individual market often excluded coverage of maternity, mental health, and substance abuse. Congressional efforts to repeal and replace the ACA during 2017 would have weakened these protections. For example, the bill passed by the House would have allowed states to alter the essential benefit requirement and waive community rating for people with gaps in coverage. The so-called Graham- Cassidy-Heller-Johnson bill drafted in the Senate would have allowed states to determine what factors insurers could use in setting rates, except for gender and genetic information, and also let states change the essential benefits. While those repeal efforts failed, changes pursued by the Trump administration through regulation and the courts have implications for people with pre-existing conditions. For example: (1) New regulations would expand the availability of short-term insurance plans, which are not required to follow any of the ACA's requirements, including guaranteed access for people with pre-existing conditions, community rating, or coverage of essential benefits. By siphoning off healthier people, these short-term plans would leave ACA-compliant plans in the individual market with a sicker pool and higher premiums. While people eligible for ACA premium subsidies would be protected from those higher premiums, those with pre-existing conditions and incomes too high to qualify for the subsidies will see higher premiums. (2) A group of state attorneys general has filed a lawsuit arguing that the ACA should be thrown out. The case argues that the ACA's individual mandate--which was previously upheld by the Supreme Court based on the federal government's power to tax--is unconstitutional now that Congress has set the tax penalty associated with the mandate to zero. According to the suit, the rest of the ACA is not severable from the mandate and should therefore be overturned. The Trump administration has filed a brief in the case agreeing that the individual mandate is unconstitutional, and that the ACA's protections for pre-existing conditions should be invalidated along with it. Polling by the Kaiser Family Foundation (KFF) finds that 64% of the public does not want the Supreme Court to overturn the ACA's protections for people with pre-existing conditions, and that continuing those protections tops the list of health issues registered voters say they'll consider in supporting candidates as the midterm election approaches.
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