There has been a great deal of discussion of the Republican promise to repeal and replace the Affordable Care Act (a.k.a. Obamacare).  One of the sticking points in trying to replace it is how to handle pre-existing conditions. Most pre-existing conditions are chronic diseases such as heart disease, cancer, arthritis or diabetes or chronic mental disorders such as bipolar disorder. The Center for Disease Control reports that in 2012, almost half of all Americans suffered from at least one chronic disease and 26% of Americans 18 years or over suffered from a diagnosable mental disorder. That means more than half of all American families have a member who may either lose coverage or have their rates skyrocket if the Affordable Health Plan is replaced with a plan that does not guarantee coverage of pre-existing conditions at affordable premiums.


Offering insurance coverage to people with pre-existing conditions is very expensive for insurance companies—that’s why they don’t want to offer it. One of the most important features of the Affordable Care Act is that people with pre-existing conditions are guaranteed coverage and, to offset the cost, everyone else must buy insurance or pay a penalty. It is that pool of healthy people who offset the cost of insuring people with pre-existing conditions.
President Trump promises to take the federal government out of health care. But he also promises to keep premiums low for everyone, drop the requirement for people to buy insurance or pay a penalty AND cover people with pre-existing conditions at affordable rates. These things cannot be done together. If the mandate to buy insurance or pay a penalty is dropped, insurance companies cannot afford to insure people with pre-existing conditions unless the government subsidizes it. If states are given a choice about subsidizing this high risk pool, many states will refuse.
Ironically, the people who voted for President Trump are the group most likely to suffer the consequences of any replacement of the Affordable Health Care Act that does not insure pre-existing conditions at affordable prices. Why? The burden of chronic disease is not shared equally. Although racial/ethnic disparities are well known, the combined influence of geographic and economic status is less well studied. (See:“Chronic Disease Disparities by County Economic Status and Metropolitan Classification, Behavioral Risk Factor Surveillance System, 2013,” Kate M. Shaw, PhD, Kristina A. Theis, PhD, Shannon Self-Brown, PhD, Douglas W. Roblin, PhD, and Lawrence Barker, PhD Prev Chronic Dis. 2016; 13: E119. Published online 2016 Sep 1).

President Trump’s strongest support is from nonmetropolitan, non-Hispanic whites, with less than a college education, and a household income of under $75,000. Shaw, et. al. found respondents in nonmetropolitan counties were significantly more likely to report chronic diseases and risk factors than were those in metropolitan counties. Differences between the most affluent and the poorest counties also varied by metropolitan classification. The largest percentage-point differences between metropolitan and nonmetropolitan counties were found for hypertension, arthritis, current smoking and body mass index classified as overweight or obese. Similarly, they found a strong association between county economic status and prevalence of chronic disease and associated risk factors.

 The prevalence of hypertension, arthritis, and poor health was lower as county economics improved.
Sadly, many of the people who screamed their approval when candidate Trump promised to "Repeal and Replace" Obamacare, did not realize the implications of that idea for their own lives. Many of them abhorred being mandated to buy health insurance, but did not understand that covering pre-existing conditions was inextricably linked to that mandate. They did not understand that covering a high-risk pool of people with pre-existing conditions necessitates offsetting them with low-risk people and forcing the latter group to buy health insurance despite being relatively healthy.