With the midterm elections approaching, Obamacare's pre-existing conditions regulations have become the focus of numerous House and Senate races, and this morning President Trump weighed in, tweeting that "Republicans will totally protect people with Pre-Existing Conditions, Democrats will not! Vote Republican." It is a statement that is designed to mislead, from a politician and a party that no longer knows how to discuss health care any other way.
Republicans will totally protect people with Pre-Existing Conditions, Democrats will not! Vote Republican.
— Donald J. Trump (@realDonaldTrump) October 24, 2018
Trump has made statements along these lines on multiple occasions. He follows other Republicans who have made similar claims, with some even going so far as to run campaign ads insisting that they support plans to regulate how insurers must treat individuals who have been sick.
Coming from most Republicans, this is a kind of obfuscation, intended to create the perception that they support the health law's suite of insurance regulations as they are.
This is typically not the case: While many Republicans voted last year for bills that would preserve Obamacare's requirements that insurers sell to everyone and not exclude pre-existing conditions, those were Obamacare repeal bills that typically would have let insurers charge more or imposed waiting periods. Other Republicans have pointed to their support for legislation that would require insurers to sell to everyone, but would allow them to exclude coverage for pre-existing conditions.
It may be possible to justify any of these positions in full or in part, since Obamacare's pre-existing conditions rules impose real costs on insurance coverage, and are responsible for a significant portion of the individual market premium hikes we have seen in recent years. The problem, as I wrote last week, is that's not what Republicans are doing. Instead, in response to allegations that they want to weaken the health law's regulations, they are implying that they support the pre-existing requirements more or less as they exist now, under Obamacare. Although there is a veneer of truth to their statements, the intention is to allow for politically convenient confusion about what Republicans actually support.
Coming from Trump, however, it is more like a lie. Earlier this year, the White House made the unusual decision not to defend Obamacare's pre-existing conditions rules in court, arguing instead that they should be severed from the rest of the law. The administration's decision, which came in response to a long shot lawsuit from a group of red state attorneys general challenging the entire law, is legally dubious, with some legal experts who have sided against Obamacare in previous court battles calling the White House position unsound. But sound or not, the Trump administration's official position in the courts is that Obamacare's pre-existing conditions rules should be struck down.
It's true that Trump is not technically saying that he supports guaranteed issue and community rating—the two major pre-existing conditions rules under the Affordable Care Act—only that Republicans support protecting people with pre-existing conditions. But Trump's policy knowledge can be described, at very best, as cursory; rarely, if ever, is he so precise as to name particular regulations. And the GOP's recent defensiveness came in direct response to criticism from Democrats arguing that Republicans don't support the rules as they exist under Obamacare. Trump's statement, like similar statements from other Republicans, is an implicit response to the charge that Republicans don't support the pre-existing conditions rules that exist under current law.
Trump and other Republicans could, of course, make a clear case against those rules, arguing that they distort insurance markets and raise costs for everyone. They could argue that Republican changes to the health law that have been branded sabotage have resulted in lower insurance premiums, more plan choice, and no significant change to the overall uninsured rate. Instead, they have adopted rhetoric that is designed to confuse people about their position regarding health insurance regulations.
On health policy, this sort of deliberate muddling of the issue has become par for the course for Republicans. One of the most striking things about last year's repeal-and-replace effort was how little effort the party devoted to explaining or defending the plan. Even more remarkable (if not exactly surprising) was how little President Trump seemed to know about what was in the plan—his first major policy initiative as president—or how it worked. At this point, it would be notable if Republicans made a concerted effort to describe and defend their health care ideas accurately.
Doing that, however, would require both rank-and-file Republicans and Trump to know and understand just what sort of health policy regime they actually support, and there is little evidence—and plenty of counterevidence—that this is a party goal.
Thus, the consistently evasive statements on health policy by GOP politicians serve a dual purpose—allowing them not only to mislead ordinary voters, but themselves as well.