The Pre-existing Condition: Innovative Solutions to America’s Thorniest Healthcare Challenge

Perhaps the most difficult challenges in healthcare policy is how to ensure that individuals with pre-existing medical conditions have access to the care they need without facing ruinous costs. The Patient Protection and Affordable Care Act (ACA) sought to find a solution in a vast, complex apparatus of individual and employer coverage mandates, guaranteed access to insurance for everyone, prohibitions against insurers charging the expected cost of insurance, requirements that some participants subsidize others, and hundreds of other provisions. In effect, the ACA sought to provide support for individuals with high healthcare costs by forcing other participants in the health insurance market to pay far more than their own insurance was worth to them. As predicted by many experts across the political spectrum, the ACA’s controversial approach resulted in most affected Americans getting a worse deal on their health insurance. 

As they craft a plan to repeal and replace the ACA that relieves Americans of these burdens, Congress and the Trump administration must still determine how to protect those facing expensive health conditions. Ideally, their solutions will be more equitable, more transparent, and less burdensome and bureaucratic than the ACA. 

In 2015, the Mercatus Center at George Mason University commissioned a set of essays in which leading policy experts shared innovative ideas on how to solve the pre-existing condition challenge. While their approaches exhibit differences, several themes recur throughout the series: 

• Address problems created long before the ACA by the tax preference for employer-sponsored insurance. 
• Policymakers should set clear, limited objectives that reflect what insurance can reasonably do. 
• The government’s healthcare policy should establish incentives for individuals to maintain continuous coverage and protections for those who do, regardless of their health status.
• The government could subsidize those facing high healthcare costs through mechanisms such as high-risk pools. 
• Healthcare policy should promote broader healthcare quality improvements and enable a vibrant healthcare market.