The facts on Cassidy-Graham and pre-existing conditions

Update: The just-released revised version of the Cassidy-Graham bill makes it even easier for states to do away with protections for people with pre-existing conditions, apparently in a vain effort to get support from Rand Paul and Ted Cruz.

Just a few years ago, many Americans with pre-existing medical conditions could not obtain health insurance at all, and many more could not purchase it at a price they could possibly afford. The Affordable Care Act -- Obamacare -- changed that. Insurance companies can no longer deny insurance to people just because they're sick or might get sick.

It has been widely reported that the proposed Cassidy-Graham healthcare bill (also known as Graham-Cassidy and Graham-Cassidy-Heller-Johnson) no longer has that requirement. Senator Bill Cassidy (R-Louisiana) has gone on news programs to deny this. He says the bill does protect people with pre-existing conditions. So which is it?

As far as I can tell, here's the story, but it's a bit complicated, and almost everything is followed by the word "But"...

The bill does require insurance companies to sell policies to people with pre-existing conditions. But...

It lets states opt out of the requirement that people with pre-existing conditions don't get charged more. It does this by letting states allow insurers to create more than one "risk pool," so people with pre-existing conditions would end up in a higher-risk pool with higher premiums. But...

It says that before they do this, states must seek approval from the federal government and provide a plan to insure people with pre-existing conditions at an affordable price. But...

It doesn't require states to actually implement such a plan, just to describe one, and as long as they produce a plan, the federal government would be required to grant a waiver to the states requesting one. (And the latest version of the bill seems to do away with the requirement to seek a waiver at all.) But...

You might say, surely states wouldn't leave people with pre-existing conditions unable to buy insurance. But...

The fact is that prior to the Affordable Care Act, almost every state did exactly that. In fact, a lot of them still do at least for some. That is, a number of states that used to restrict Medicaid to just a subset of poor people continue to do so. The Affordable Care Act required them to expand Medicaid and ensured that almost all of the additional cost would be covered by the federal government. However, the Supreme Court discovered something supposedly in the Constitution that made this optional (though it's a little unclear where in the Constitution they found this -- perhaps Nicolas Cage ran across it on the back, presumably in a deleted scene from National Treasure). People whose income puts them in the Medicaid expansion group often can't get insurance on the exchanges if they live in one of the states that refused to expand Medicaid, so their states force them to go uninsured, pre-existing conditions or not.

There's a reason (besides sheer meanness) states would want to make coverage for pre-existing conditions expensive or unaffordable: To force people to buy and maintain health insurance coverage without explicitly doing so. Right now the Affordable Care Act encourages people to get health insurance by charging them an extra income tax if they don't have it and don't belong to one of the exempt categories (such as those with a religious objection to health insurance). A lot of people want to do away with this so-called "individual mandate." The problem is that if they did so, a lot of people would just go without insurance until they got seriously injured or ill. And that would obviously raise the price of insurance sky-high, just as homeowners insurance would be horrendously expensive if you could wait until your house burned down to buy it. If you do away with the ACA's individual mandate and you still want people to buy insurance, the only alternative is to scare them into buying it by letting them know it will cost a lot more if they wait. The problem is that experience shows lots and lots of people just don't think ahead or assume that because they're pretty healthy now they can't possibly get sick or hurt.

The bottom line is that we can be close to certain, based on experience and on what a lot of Obamacare opponents stay publicly, that a lot of states would opt out of protection for people with pre-exisiting conditions. The bill's supposed "protection" is either poorly thought out or else a deliberately cynical con job to give political cover to people voting for it. Either way, it's one of the things that makes it a bad bill. But...

It's far from the only problem. The bill also deeply slashes funding (though the latest revises version dumps more money into it) and converts much of the Medicaid expansion and premium assistance money to block grants to states, with few regulations on how the funds are used.

Not one major medical or consumer organization supports the bill, and odds are any of those organizations whose name you've heard actively opposes the bill.

The latest news reports suggest that the bill is probably dead and likely won't even come up for a vote. That's not a certainty, however. So if you want to do something in the limited time available, here from Time magazine is a list of direct contact numbers.

Especially if you live in a state with a Republican senator you should give them a call. You'll wind up talking to a staffer, who no doubt has a script to read telling you that Obamacare is collapsing and something must be done. That's not actually true, but don't waste time arguing with them. Make sure they know you're from their state. Tell them what city or county you live it. Say you agree that Obamacare has flaws (which is true) but that the Graham-Cassidy bill is even worse and has never had open hearings or debate. Say that you support Senator John McCain's call for a bipartisan solution. (See what McCain says here.) It's OK to let them know you're passionate about it, but avoid yelling and the poor staffer answering the phone. If they're stubborn, just say you disagree with them and you'd like them to pass on your views to the senator.

Even senators who won't change their minds still keep track of how the call volume goes and pass on the information to their colleagues.

What if your senators are both Democrats? It's still good to call and let them know you don't want to Graham-Cassidy bill to pass. Ask them what you can do to make sure that doesn't happen.

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