Why Republicans Lost the 'Pre-Existing Conditions' War

Michael F. Cannon

For this week’s elections, Democrats spent considerable resources attacking Republicans for trying to tamper with Affordable Care Act rules that require insurers to cover preexisting conditions. Now that voters have handed Democrats control of the House, ObamaCare supporters claim the election confirms what nearly every public opinion poll finds: The ACA’s preexisting-conditions provisions are popular with voters.

Don’t believe it. Truth is, the supposed popularity of the ACA’s preexisting-conditions provisions is — and always has been — a myth.

Polls and attack ads that claim the provisions are popular are based on a fantasy version of these rules that assumes they have no costs. Responsible polls that incorporate the rules’ known side effects consistently find voters oppose them.

Let’s be blunt: ObamaCare’s preexisting-conditions provisions impose substantial costs on patients and taxpayers. They are the main reason premiums doubled in the law’s first four years. They necessitated much of the ACA’s $1 trillion in new taxes.

Indeed, these rules are so destabilizing, they necessitate prohibiting consumers from purchasing ACA coverage for nine months of the year, denying care to some patients. They also forced lawmakers to pass the mandate for all Americans to have insurance, in the hope that healthy folks would generate profits to offset the costs. Last year’s tax-cut legislation removed that penalty.

Plus, ObamaCare’s preexisting-conditions provisions actually make health coverage worse. Economists of all political stripes acknowledge these rules have the unintended consequence of penalizing insurers who offer high-quality coverage.

Empirical research confirms that the rules are responsible for making coverage progressively worse for patients with multiple sclerosis, rheumatoid arthritis and other expensive conditions. A coalition of 150 patient groups confirms this is happening in myriad ways, from narrower choice of doctors and hospitals to skimpier drug coverage — a dynamic that “completely undermines the goal of the ACA.”

You’d never know any of this from listening to pollsters, who typically ask voters only about the promised benefits of these rules — i.e., that sick people get health care coverage. It’s no wonder as many as 81 percent of voters say they approve. Who wouldn’t approve of a policy that was all benefits and no costs?

Yet these tradeoffs matter to voters. My colleague Emily Ekins has released new polling data showing that, when asked only about the benefits, voters support these rules 65 percent to 32 percent. But things change dramatically when voters consider the inevitable costs.

• If voters are told these rules lead to higher taxes — which they do — support falls to 51 percent, and opposition climbs to 44 percent.
• If told they drive up premiums — and they do — support falls to 49 percent, and opposition rises to 47 percent, a statistical dead heat.
• If informed that they worsen the quality of care, such as by reducing access to tests and treatments for some patients — and they do — public support flips: Overall support falls to 44 percent, with 51 percent opposed. Driving that reversal is a nearly 30-point drop in support among Democrats alone.

The results are consistent across polls Ekins conducted in 2013 and 2017, and even a 1994 Gallup poll: Voters care about costs as well as benefits — and don’t mess with the quality of their care. Democrats may have ridden their health care message to victory, but it was still based on a myth.

One can hardly shed a tear for Republicans, however. Washington Post fact-checker Glen Kessler marvels that GOP candidates never pressed the powerful and perfectly valid line of attack that ObamaCare’s preexisting-conditions provisions harm quality.

Instead, GOP leaders advanced a so-called ACA repeal bill that would have preserved these rules and even sped up the decline in quality.

Republicans lost the House not because the ACA’s preexisting-conditions provisions are popular. They lost because they refused to tell voters how those rules harm the quality of care. Maybe the beating they took this week will spur them to start taking health care quality seriously.

Michael F. Cannon is director of health policy studies at the Cato Institute.