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

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The provision of the PPACA that forbids insurers from chargingmore to customers with preexisting conditions is one of the fewaspects of the law that members of both parties are reticent tocriticize, and which enjoys broad popularity among the public.

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

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

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What remains to be seen is how setting up high risk pools, whichexisted before the PPACA, would reduce costs across the entiresystem. While premiums in the rest of the insurance pool may dropby getting rid of the most expensive customers, a pledge tosubsidize the risk pools that they are shifted to means thattaxpayers will still be paying for their care.

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

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

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If anything, Democrats hope that the upcoming election willput them in a position to expand the law at both the state andfederal level, although it’s not clear how or to what extent. WhileBernie Sanders’ “Medicare-for-all” plan isunlikely to be realized, a Democratic Congress could move tofurther expand Medicaid funding to states. And moves by Democratsin California to allow undocumented immigrants in that state accessto the PPACA marketplace shows how state lawmakers might championtheir own reforms.

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

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

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However, that poll and another recent one by the Kaiser FamilyFoundation reveals that distaste for the PPACA also comes fromliberals who do not believe the law goes far enough in reformingthe health care system.

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

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“This increase may be due to the rhetoric surrounding universalhealth care in the Democratic presidential campaign, with bothcandidates advocating universal coverage as a goal,” stated theKaiser report.

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Neither of the recent polls asked respondents to opine onwhether insurers should be required to cover those with preexistingconditions, but previous polling has suggested that arguing againstthat provision would be potentially perilous for Republicans.

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