Midterm voters control the future of health insurance

Despite promising to repeal it, the Republican-led Congress has left the Affordable Care Act on the books. And despite the Trump administration’s efforts to undermine it, the law’s still working pretty well. Its future success, though, can’t be taken for granted.

As the midterm elections approach, and concerns over the health-care system grow, voters ought to take stock of the harm that has deliberately been done — piece by piece, with effects now and in future — to an initiative that the U.S. badly needed.

Related: Trump administration won’t defend Obamacare

Granted, some 30 million Americans are still uninsured — but that’s 20 million fewer than before the ACA. Most of the newly insured have signed up for Medicaid in the more than 30 states that have expanded enrollment. Millions of others with incomes low enough to qualify for federal premium subsidies have bought affordable, comprehensive Obamacare policies. That’s real, substantial progress.

Yet the system stands to deteriorate in years ahead, because President Trump, having failed to persuade Congress to repeal Obamacare, has been working to sabotage it. His administration is enabling the sale of low-quality health insurance, and making it harder for people to sign up for Obamacare plans. It’s also pushing in court to do away with Obamacare’s popular protection for people with diabetes, high blood pressure, depression, obesity and other pre-existing conditions.

The administration is sanctioning two kinds of substandard insurance: short-term policies and association health plans.

Short-term policies can deny coverage for pre-existing health conditions, and for Obamacare’s 10 essential health benefits, including hospitalization, prescription drugs and maternity care. That’s bad enough for plans that last only a few months — to tide people over between jobs, for instance. But under a new rule from the Department of Health and Human Services, such supposedly short-term plans are allowed to run for three years.

Association health plans, sold to trade associations and business groups such as chambers of commerce and farm bureaus, have existed for decades. But they have been so prone to fraud and insolvency, the ACA reined them in with new reporting rules, and required that they cover pre-existing conditions and essential health benefits. Now the Department of Labor has loosened the rules, expanding the kinds of associations allowed to create health-care plans and treating these offerings under the law as large-employer plans. That means they need not cover the 10 essential health benefits, and they can charge some people more based on their gender or profession.

Of course, one gets what one pays for, so short-term and association health insurance plans will be cheaper than good-quality ACA plans. They will attract people healthy enough to risk getting by without decent insurance. But as these plans siphon millions of people from the Obamacare marketplaces, the average costs for those left behind will rise, pushing up premiums.

This undermines the very foundation of insurance: the pooling of risk by large numbers of people, healthy and sick alike, to keep premiums under control and make sure no one runs up against unaffordable medical bills.

Adding insult to injury, the Trump administration is now encouraging ACA navigators — the federally funded outreach groups that guide Americans through the ACA insurance marketplace — to help people sign up for these competing, corrosive low-value plans. This, on top of earlier moves to slash funding for outreach and advertising, shorten the fall enrollment period to six weeks (from 12), and, while enrollment lasts, shut down the ACA website for half a day every weekend. Vandalism is rarely this thorough.

But there’s more. Contributing to the upward pressure on premiums is the elimination next year of the individual mandate — that is, the tax imposed on those who choose to be uninsured.

And, finally, the most recent White House assault: The Justice Department is siding with the 20 states now suing to dismantle the reform. The states charge that, without the individual mandate, the law’s protection for people with pre-existing conditions is illegal. This position is so outlandish that even many critics of Obamacare refuse to go along. “Everybody I know in the Senate, everybody is in favor of maintaining coverage for pre-existing conditions,” Senate Majority Leader Mitch McConnell said.

McConnell predicted the lawsuit will fail — which would be a stroke of good fortune for both the ACA and the Republican Party going into the fall elections. But it wouldn’t be enough to stabilize the U.S. health-care system in the face of Trump’s other attacks.

States can fight back — by enacting individual mandates of their own, by demanding that insurers provide essential health benefits, by creating reinsurance programs to stabilize Obamacare markets, and by putting reasonable limits on short-term policies and association health plans. Several states have already begun to take such actions, but some are moving in the opposite direction, paving the way for substandard Trumpcare. If they prevail, Americans’ access to quality health care will increasingly depend on where they live.

The midterms are important for other reasons, too — but the future of U.S. health insurance should be high on the list of citizens’ concerns. In choosing candidates for state government and for Congress, voters should look for candidates who promise to protect and expand the gains in health-care coverage that the ACA has achieved.

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