House Speaker Paul Ryan says that some of the Patient Protection and Affordable Care Act’s (PPACA) protections for the sick need to go.

The provision of the PPACA that forbids insurers from charging more to customers with preexisting conditions is one of the few aspects of the law that members of both parties are reticent to criticize, and which enjoys broad popularity among the public.

However, Ryan contends that that provision is driving up costs for everybody else. The most expensive customers, he said, should be moved to high risk pools run by states.

"Let's fund risk pools at the state level to subsidize their coverage, so that they can get affordable coverage," he said during a talk at Georgetown University. "You dramatically lower the price for everybody else. You make health insurance so much more affordable, so much more competitive and open up competition."

What remains to be seen is how setting up high risk pools, which existed before the PPACA, would reduce costs across the entire system. While premiums in the rest of the insurance pool may drop by getting rid of the most expensive customers, a pledge to subsidize the risk pools that they are shifted to means that taxpayers will still be paying for their care.

What Ryan appears to be proposing is simply shifting more of the payment burden to those with preexisting conditions, but offering subsidies to ensure that their insurance is still affordable. Indeed, in outlining its vision last week for high risk pools, the conservative Republican Study Committee suggested capping premiums for members at 200 percent of the average premium in a state.

Ryan’s proposal is not likely to be embraced by any Democrats and will likely be spurned by many Republicans, including Donald Trump.

If anything, Democrats hope that the upcoming election will put them in a position to expand the law at both the state and federal level, although it’s not clear how or to what extent. While Bernie Sanders’ “Medicare-for-all” plan is unlikely to be realized, a Democratic Congress could move to further expand Medicaid funding to states. And moves by Democrats in California to allow undocumented immigrants in that state access to the PPACA marketplace shows how state lawmakers might champion their own reforms.

By moving to expand the PPACA, Democrats are responding to their base, which has been energized by calls from Sanders and others to shift the health care system to resemble more closely those that exist in other western countries.

Polls continue to show a public that remains deeply divided on the PPACA. A recent survey by Pew found 44 percent of Americans approve of the law, while 54 percent disapprove.

However, that poll and another recent one by the Kaiser Family Foundation reveals that distaste for the PPACA also comes from liberals who do not believe the law goes far enough in reforming the health care system.

The Kaiser poll, which had support for Obamacare at only 38 percent, found that 51 percent of Democrats (including many favorable to the PPACA) say that they would like to see the law expanded. And among the quarter of self-described Democrats who say they don’t approve of the PPACA, 40 percent say they want to see it expanded.

“This increase may be due to the rhetoric surrounding universal health care in the Democratic presidential campaign, with both candidates advocating universal coverage as a goal,” stated the Kaiser report.

Neither of the recent polls asked respondents to opine on whether insurers should be required to cover those with preexisting conditions, but previous polling has suggested that arguing against that provision would be potentially perilous for Republicans.

Instant Insights /

Paul Ryan says preexisting conditions provision of PPACA must end

More From HR Executive

Related Stories

Recommended For You