Since he began running for president, Donald Trump has been lying about health care in general, and protections for patients with preexisting conditions in particular. Trump’s long-standing lie is that he has a plan to help people with preexisting conditions afford insurance, or will shortly unveil such a plan. His most recent version of this lie goes even farther. Trump is now saying that he actually created the protection for preexisting conditions, and that Democrats are trying to take it away:
This is the literal polar opposite of reality.
Before Obamacare, the individual health-care market was dominated by a practice called medical underwriting, in which insurers would sell plans to people based on their expected cost. A person with a healthy history could buy a pretty cheap plan, but somebody with a history of expensive medical needs would have to pay a lot more — sometimes, insurers would refuse to cover any treatment for preexisting conditions. One of the main accomplishments in Obamacare was to regulate the individual market, so that insurers could no longer charge different rates to customers based on their medical status.
The 2017 Republican plan severely weakened those regulatory protections by allowing states to permit insurers to charge lower rates to healthy customers and higher rates to sicker ones. That is the plan Trump celebrated when it passed the House, and has continued to lament when it died in the Senate (after John McCain’s famous thumbs-down). Having failed in Congress, Trump has instead turned to the courts. His lawyers are currently supporting a lawsuit to overturn Obamacare, including its protections against discrimination on preexisting conditions.
So, Democrats created protections for people with preexisting conditions, and Trump’s ongoing legislative and legal strategy is to eliminate those protections. Yet he claims just the opposite — that he created the protections, and Democrats are trying to undo them.
The question of why Trump would be willing to lie about this is obviously uninteresting. (He is a gigantic liar.) The more interesting question is why he has to lie about this. Trump obviously recognizes that protections for preexisting conditions are popular, and the attacks on his position are potent. So why is he forced to lie so blatantly, instead of simply abandoning his highly unpopular stance?
The answer is that the logic of Republican health-care policy demands it. The party declared Obamacare to be a socialist monstrosity bound to collapse. The first piece of evidence Republicans could find for their conclusion was when insurance regulations began to take effect at the end of 2013 — that’s when insurers had to cancel plans based on medical underwriting and begin selling new policies that ignored preexisting conditions. One result of these regulations is that the handful of people who had passed medical underwriting and had purchased cheap plans based on their good health had to purchase insurance that was more expensive, because they were now sharing costs with sick people.
Conservatives seized on this development. It was “rate shock” for the young and healthy, and proof that Obama had lied when he promised people could keep their plans. Undoing these regulations became the core Republican health-care promise. They would reverse “rate shock” by giving people the choice to buy skimpy plans that didn’t cover preexisting conditions. Their favorite example of Obamacare regulation run amok was the requirement to cover maternity care; their whole rationale was that people should only have to buy insurance that covered medical treatments they expected to pay for. The sales pitch was that young, healthy people without preexisting conditions would be able to go back to buying skimpy insurance. But of course, this also meant people with preexisting conditions would have to pay a lot more.
The once-fanatical passion Republicans attached to their hatred for Obamacare has subsided, but the party has never revisited its eliminationist dogma. The party’s formal legislative and legal stance remains wedded to overturning protections for people with preexisting conditions. Republicans still want to let insurers charge astronomical rates to people with preexisting conditions, however unpopular that stance would be, because to them anything is better than admitting Obama was right.