Republican vice presidential nominee JD Vance’s plan to overhaul the health care law signed by President Barack Obama is vague on details, but many conservative health experts say it would take the Republican Party back to a place it doesn’t want to go.

Vance’s comments last week added some detail to Republican presidential candidate Donald Trump’s claim during the Sept. 10 presidential debate that he had a “concept of a plan” to reform the Obama-era health care exchanges.

“We’re actually going to implement regulatory reform in the health care system that allows people to choose a health plan that’s right for them,” Vance said at a campaign rally in Raleigh, North Carolina, last week, adding that people who use the Those in the health care system often have a different plan than those who are healthy and go to the doctor less often.

“This will now also result in people with similar health situations being in the same risk pools,” the Ohio senator added.

Republican health policy experts say Vance’s comments could indicate one of several policy changes: restructuring insurance risk pools, expanding transitional reinsurance programs or reinstating Trump-era changes to short-term, limited-term plans.

Or it’s possible he’s just improvising.

“I’m not sure he knows what he means,” said Chris Pope, a senior fellow at the Manhattan Institute, a conservative-leaning think tank. But Pope acknowledged that politicians don’t often go into extreme policy details during campaigns.

Sen. Bill Cassidy, R-La., the ranking Republican on the Senate Health, Education, Labor and Pensions Committee, was heavily involved in the repeal and replace effort in 2017 and said he needed to see more details on Vance’s plan before making a ruling fall.

However, he noted that returning to risk pools could be challenging.

“The actuarial case would be difficult,” Cassidy said of dividing the sick and healthy into different insurance risk pools.

“There have been some issues with adverse selection in the past,” he added.

The Trump-Vance campaign did not respond to a request for comment.

The focus on health care policy, particularly the 2010 changes to the health care law, is unusual for this 2024 campaign. In April, Trump stressed he was not interested in changing or repealing the law.

That statement marked a shift since Trump’s presidency, when he fought for deregulation or even repeal of the law. After several failed attempts, Trump – and the Republican Party – moved on.

But in this election cycle, it is Vance, not Trump, who is taking the political lead in the campaign. Vance was not a member of Congress during the Trump administration, when Republicans made significant efforts to repeal and replace the health care law.

Policy experts who support changes to the health care law are skeptical that overhauling the law would be a priority or even feasible for a Trump-Vance administration.

“Do I think this is something that Trump and Vance care about or that they will push for it themselves?” said Michael Cannon, director of health policy studies at the libertarian Cato Institute. “I’m not holding my breath.”

Risk pools

During an appearance on “Meet the Press” on September 15, Vance first unveiled changes to health insurance risk pools.

“Think about it: A young American does not have the same health needs as a 65-year-old American. “A 65-year-old American in good health has very different health needs than a 65-year-old American with a chronic illness,” Vance said, while criticizing the “one-size-fits-all approach that puts a lot of problems in putting people in the same insurance pools.”

High-risk pools that distribute health care costs only to people with certain pre-existing conditions are largely obsolete following the implementation of the 2010 health care law, which required insurers to cover people with pre-existing conditions the same as healthy people. This puts everyone in one risk pool and everyone pays the same insurance premiums regardless of their health status.

Mandatory coverage for high-risk pools quickly became one of the most popular parts of Obama’s health care law.

But some Republicans have stuck with the idea of ​​risk segregation in insurance markets, even though coverage for people with pre-existing conditions is widespread. Proponents of using high- and low-risk pools argue that this method can allow insurers to offer cheaper plans to people with lower expected needs.

“The existing conditions in Obamacare undermine universality,” Cannon said.

Cannon argues that preventing insurers from discriminating against people with pre-existing conditions in enrollment does not change the economic reality of covering these more expensive conditions.

“They’ve just made it impossible for insurers to be transparent about how they deal with them, and so they’ll deal with them in less transparent and more damaging ways,” he said, referring to the exchanges.

Republicans tried to change risk pools in 2017. Trump and then-House Speaker Paul D. Ryan, R-Wis., promoted a $15 billion federal high-risk pool to provide insurance coverage to Americans with pre-existing conditions, lowering costs for healthy people. The bill failed in the Senate due to the infamous opposition of Republican Senator John McCain of Arizona.

It is possible that Vance’s plan does not call for two separate risk pools on the exchanges, Pope suggested.

Instead, those currently on the health care exchange who like their plans could stay with their plans and continue to receive all of the law’s protections, including coverage for pre-existing conditions as well as the 10 essential health benefits, which include preventative care, laboratory services and mental health Health.

But healthy individuals who don’t need coverage for pre-existing conditions and may want to pay less could opt for another government-sponsored insurance plan that would cost less, Pope explained.

Still, most Republican policy experts say it’s not smart policy and could lead to higher federal spending, a larger deficit and more government involvement in health care markets.

“From a rational standpoint, it doesn’t make sense,” said Joe Antos, senior fellow emeritus at the conservative American Enterprise Institute.

“You can’t do it like that. You need a few healthy people and a few sick people. Otherwise there will be a financially unsustainable system,” Antos added.

reinsurance

Ed Haislmaier, senior research fellow at the Heritage Foundation’s Center for Health and Welfare Policy, said campaign remarks tend to be high-level and conceptual compared to the details of actual regulations and laws.

“The problem here is that people read into a general observation details that may not be there,” he said.

However, the general proposal, as he interprets it, refers more to a subsequent restructuring of risk pools between insurers.

“In other words, everything would be the same for those enrolled. You wouldn’t see any difference,” Haislmaier said. “What you’re doing is moving the dollars around.”

Haislmaier said if this is the policy, it is something that has been successful under both Republican and Democratic administrations and could work on a broader scale.

For example, states can currently apply for state innovation reinsurance waivers under Section 1332, which allow market subsidies to be paid directly to the state for redistribution rather than being transferred directly to the insurer.

“There is work being done to lower premiums in states, and that includes red states and blue states,” he said, adding that the next Congress could also include a discussion about how to expand that process could be rationalized.

Other options

Republicans on Capitol Hill are pushing other changes to reduce costs on federal health exchanges that don’t involve separating risk pools, such as codifying the Trump rule for short-term plans or expanding association health plans.

The Trump administration expanded short-term health insurance plans to 12 months. The plans were traditionally intended to be a cost-effective and scarcer insurance option for people in times of transitional insurance. The Biden administration repealed that rule because many Americans bought the cheaper plans without realizing they had little consumer protection, and again limited the plans to four months.

Republicans on Capitol Hill criticized the move. Cassidy and Mike Braun, R-Ind., said the move “forced individuals and families into plans that are more expensive and less tailored to their needs.”

House Republicans also support expanding association health plans, which are offered by employer groups that have banded together and are not required to follow the parameters of the 2010 health care law.

The Trump administration’s 2018 rule was overturned by a federal judge in 2019 before it could take effect, although the Trump administration attempted to appeal that decision. The Biden administration proposed repealing the 2018 rule.

Earlier this month, Republicans on the House Education and Labor Committee voted in favor of a Congressional Review Act resolution seeking to block the Biden administration’s rule restricting access to association health plans. Republicans argued that the plans help small businesses reduce their employees’ health care costs.

A messaging problem

Right-wing political experts largely agree that the Trump-Vance campaign faces a communications problem on health insurance policy. Cost reductions are the trend. A reassessment of the 2010 health care law is not the case.

Antos encouraged the Trump-Vance campaign to take a leaf from Democratic presidential candidate Kamala Harris’ campaign playbook and talk more broadly about health care costs when talking to voters. Republicans tried for years to repeal and replace the 2010 health care law but failed. They say voters have largely defected and lost interest.

“Health insurance is clearly not a very relevant issue for the election,” Antos said. “I’m not saying the insurance problems are solved. It’s just that they’ve really been minimized. Basically, the ACA (the 2010 health care law) worked.”