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This Senate Democrat has a plan to end preexisting conditions for good

No senator knows preexisting conditions better than Tammy Baldwin.

Astrid Riecken/Getty Images
Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

Sen. Tammy Baldwin (D-WI) was labeled with a preexisting condition when she was just 9 years old. Today, she is readying a countermove to the Trump administration’s recent push to expand policies that could bring preexisting conditions roaring back onto the insurance market.

“There are so many parents or foster parents or grandparents who either worry about financial ruin if they get a sick child what they need or they worry: `Can we hold off, can we hold off?`” she said while recounting her own family’s experience.

The Trump administration recently proposed new regulations that would allow short-term insurance plans, currently limited to three months, to be sold for an entire year. Those plans are not subject to the same rules as health insurance sold under the Affordable Care Act. They can deny people coverage based on their health status, charge sicker and older people higher premiums, and limit their benefits.

Baldwin is preparing to introduce legislation, shared exclusively with Vox, that would block the Trump administration’s proposals. Her bill would aim to, in effect, eradicate the concept of preexisting conditions for good.

Even though short-term plans would still be permitted, they could no longer escape Obamacare’s core protections. They would be prohibited from denying people coverage based on their health status or charging sicker people higher premiums; they could not have annual or lifetime limits. They would also be limited to three months by law and they would be non-renewable, as the Obama administration had decreed by regulation.

“I think this really allows policymakers, elected officials, to show which side they’re on. Most of them promised their constituents at town hall meetings during the debate last year: `I will protect people with preexisting conditions,’” Baldwin told me in an interview Thursday. “This allows them to show in a public way which side they’re on and whether they’re keeping faith with that commitment made to their constituents.”

Under the Trump administration’s proposal, health policy experts say that young and healthy people would flock to those non-Obamacare plans and premiums would increase for the older and sicker customers left behind in the health care law’s marketplaces. A recent Urban Institute analysis projected an 18 percent premium hike in more than 40 states under the expanded short-term plans when combined with the Republican repeal of Obamacare’s individual mandate.

“We’ll see another huge premium increase because of that,” Baldwin said. “The administration isn’t looking at the whole picture and is being disingenuous because they’re smart enough to look at the whole picture.”

Her legislation faces a steep, probably insurmountable climb to becoming law, with Republicans controlling Congress and President Trump in the White House. But Baldwin could theoretically have several opportunities, either with an Obamacare stabilization bill that could pass later this month or by deploying a congressional process for reversing federal regulations, to try to force the issue.

There is probably no senator better positioned to talk about protections for preexisting conditions, which have become overwhelmingly popular in the eight years since the ACA was passed. Below is my conversation with Baldwin, edited for clarity and length.

Dylan Scott

What’s your preexisting conditions story?

Tammy Baldwin

It starts with the fact that I was raised by my grandparents. They started taking care of me when I was two months old.

When I was 9 years old, I got a very serious childhood illness. Usually, for nonmedical experts, I say it was very similar to spinal meningitis with regard to severity and symptoms. But it wasn’t that.

I was in the hospital for three months. I went into the hospital with an 107, 108-degree fever. Because of wonderful care, I completely recovered.

Dylan Scott

Three months is such a long time.

Tammy Baldwin

Especially the younger you are, the longer that time is. Three months is a blip for somebody in their 50s. But when it’s a significant slice of the pie of your entire life, I remember it well.

My grandparents were fabulous. They of course didn’t burden me with any of the financial aspects of my hospitalization or recovery. But over the years, I learned two things. They had a family plan that didn’t consider grandchildren dependents. So there was the back-and-forth fight of who is going to pay this hospital bill. They said, “Well, we have insurance.” They were told, “Well, this doesn’t cover the ill one.”

I don’t know in the end how much they paid out of pocket. But I know it was a significant amount. They thought they had to fix this, they had to get me insurance. But despite my full recovery, which is irrelevant in actuary world, I was considered a child with a preexisting condition.

So they couldn’t find insurance to cover me at any price. They got “no” as an answer, not “if you pay hundreds of dollars a month, we’ll cover her.” So I, fortunately, was very healthy the rest of my youth, but I didn’t have insurance until I was a college student.

Dylan Scott

Did the preexisting condition issue ever come up again?

Tammy Baldwin

I was briefly employed where they didn’t have a group plan. My first insurance out of law school, they said, “generally, you have a health insurance, but we won’t cover X, Y, and Z” and that related to preexisting conditions. Fortunately, that was never an issue.

In a nutshell, that’s what I experienced. In terms of my motivation to be involved in public service and policymaking, that story is really at the core of it. I know my grandparents worried. I know that when you have a responsibility for a child, these things keep you at night. There are so many parents or foster parents or grandparents who either worry about financial ruin if they get a sick child what they need or they worry: “Can we hold off, can we hold off?”

In the debate, when I was in the House, when the ACA was passed, obviously one of the biggest achievements was protecting people with preexisting conditions from being denied health insurance or being charged unaffordable rates.

Dylan Scott

I have to admit, I was slow to pick up on how much of a rallying cry preexisting conditions had become. That seems to be one of the core achievements that people identify with the ACA. Preexisting conditions sounds so jargon-y, but it seems like for the American people, the preexisting conditions protections have really stuck with them.

Tammy Baldwin

I think it is something that, prior to the passage of the ACA, had become a more and more urgent problem, especially as insurers became more sophisticated about how to try to insure the healthiest and the wealthiest, right?

One of the points I made about my being labeled a child with a preexisting condition is important here. I had fully recovered. I had no more chance than any other human being of getting again what I had. There are other conditions where you have recurrences or relapses. I wasn’t in that category. But this idea of defining once having an expensive illness or injury as you have a preexisting condition means that so many more people are included as people with preexisting conditions.

An actuary is looking at this expensive illness, this long hospitalization, and they’re doing math formulas and saying this person could be expensive in the future because they were expensive in the past. What I think we’ve found while we were debating the ACA is a really big share of Americans were people with preexisting health conditions.

It wasn’t just things you might think of as preexisting condition. If there was something in your medical record or in the public record about a history of domestic abuse, that could be considered a preexisting condition.

Dylan Scott

So on the one hand, I know progressives describe what the Trump administration is doing with short-term insurance plans and other policies as sabotage and as ways to undermine the ACA. The way the administration frames it is there are millions of people who are uninsured, there are some people for whom ACA coverage has become unaffordable and we’re just trying to give them an alternative.

Why shouldn’t people think the administration is just trying to give people some other kind of coverage they could buy?

Tammy Baldwin

I think it’s appropriate to use words as emphatic as sabotage because so many of these proposals are going to lead to more people being uninsured and others who have been able to afford care to no longer be able to afford it. You don’t fix this through policies that destroy a health care program for everyone else. Based on the evaluations of these proposals, they have such devastating impacts for folks who are still participating in the Affordable Care Act.

Particularly on the short-term policies, it’s gonna have a number of really negative impacts. It’s not real insurance that has comprehensive coverage. By its very definition, it doesn’t have to adhere to the protections of the ACA, particularly concerning preexisting conditions. So people will be turned away or charged a lot more to make it unaffordable.

I fear people will think they’re signing up for real health care, that they won’t read the fine print. Some will move from ACA coverage to short-term coverage, which is no longer short term under this proposed rule, and leave a less healthy, aging group of Americans in the ACA. Then we’ll see another huge premium increase because of that.

Basically, the administration isn’t looking at the whole picture and are being disingenuous because they’re smart enough to look at the whole picture.

Dylan Scott

I’ve looked at your Fair Care Act, your response to these rules. I thought, taking all the particulars together, it seemed like you were looking for a permanent way to close any potential for loopholes, where you create a non-ACA marketplace that would have the detrimental effects that you were describing.

Tammy Baldwin

I think this really allows policymakers, elected officials, to show which side they’re on. Most of them promised their constituents at town hall meetings during the debate last year: “I will protect people with preexisting conditions.” This allows them to show in a public way which side they’re on and whether they’re keeping faith with that commitment made to their constituents.

Dylan Scott

On that point, do you really see a viable path for this to become law? It’s really hard to imagine this becoming law anytime soon, given political realities.

Tammy Baldwin

I think it’s an opportunity to again keep faith with the commitment that most of my colleagues made to their constituents, that there would be coverage for them that’s affordable, that would be provided regardless of preexisting conditions. “Where are you on this?” If we talk about it in that way, I think there are a lot of members who will want to clarify to their constituents what side they’re on.

Dylan Scott

To take a longer view, something that I think has been interesting in the progressive discussion about health over the last year has been a recognition that the ACA has been vulnerable to some of the things that the Trump administration has now been able to do administratively to undermine it.

It’s my sense that is driving some of the discussion about more expansive health care programs, whether that’s Bernie Sanders’s Medicare for All bill or the Center for American Progress’s Medicare Extra for All plan.

How do you feel about those proposals? Because it seems like that is the most foolproof way to make sure preexisting conditions never come back.

Tammy Baldwin

Immediately following the defeat of the repeal effort, a lot of people understood that wasn’t the end of the discussion. The ACA needed fixing and it’d been neglected after years of Republican resistance. So the improvements that should have been made to any complicated piece of legislation weren’t.

After that vote, you saw the Alexander-Murray process begin. But you also saw people introducing innovative ideas to strengthen the ACA and to use time-tested programs to do so. I not only signed onto Medicare-for-all, but I also signed into a Medicare buy-in, I also signed into a novel idea of buying into Medicaid. Public options in the Affordable Care Act, especially for areas with fewer insurers.

I think there was time where everything needed to be on the table. I didn’t foresee at that moment that the tax bill would repeal the individual mandate, that Trump would have this administrative rule on short-term policies, and the additional acts that would undermine the ACA. I thought maybe we had a breathing point to start about these ideas.

Dylan Scott

I think there is a debate among progressives about incrementalism versus universalism. Is your long-term outlook that there needs to be a universal single-payer program?

Tammy Baldwin

I would say I can walk and chew gum at the same. There are urgent fixes that need to happen quickly. The prescription drug issue, the recent complete lack of accountability with the pharmaceutical companies doubling the prices of life-saving drugs. The ACA aside, if your EpiPen is unaffordable, your multiple sclerosis is $90,000 a year, if your insulin prices have doubled, you have an emergency right now.

I can look at the stabilization measures, my new bill, that’s focused on the shorter and medium term, and I can also say that we can never stop thinking about creating a more perfect union. We can never take our eyes off the long term, too.

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