by Leslie Small
Since at least the 2017 saga when Republicans tried to repeal
and replace the Affordable Care Act (ACA), one of the law's most visible — and
politically charged — components has become its protections for people with
preexisting conditions. Now, with the makeup of the Supreme Court slated to
shift, some experts believe those same provisions are the most at risk from
being struck down alongside the law's now-defunct individual mandate.
But that begs the question: Would health insurers actually want
to go back to a pre-ACA world?
"No, they so do not want that to happen," says Chris
Sloan, an associate principal at Avalere Health. Before the ACA was enacted,
"it wasn't that they [insurers] liked medically underwriting…it's just
that anybody who didn't would get all the bad risk and their health plan would
collapse," Sloan explains.
Katie Keith, a health care attorney and faculty member at
Georgetown University's Center on Health Insurance Reforms, says that companies
that are already underwriting short-term, limited-duration plans "could
jump right in" and underwrite more plans if parts of the ACA are struck
down. But other insurers might not even have the infrastructure to do so
anymore, having given up their underwriting divisions after the ACA was enacted,
she observes.
About 54 million people currently have a preexisting condition
that could have resulted in them being denied coverage in the pre-ACA
individual market, according to a new analysis from the Kaiser Family
Foundation. The ACA required insurers in the non-group, small-group and
large-group markets to issue coverage regardless of health status and
prohibited non-group and small-group plans from varying premiums based on
health status or gender, among other protections for preexisting conditions.
In Sloan's view, insurers would prefer to keep operating in a
post-underwriting world mainly because "they like that everybody plays by
the same rules across the markets" so that they can compete more fairly.
Sloan also points out that "disruption is challenging — I
mean, just think about how long it took to get the ACA and the individual
markets to a sort of stable place." Therefore, insurers "above all
else value stability in markets, and in particular, stability when it comes to
rules and regulations," he adds.
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