Most Republicans in Washington are trying furiously to convince the public that their Obamacare repeal proposal wouldn’t punish people with pre-existing medical conditions. Rep. Mo Brooks (R-Ala.) isn’t one of them.
During an interview with CNN on Monday, Brooks acknowledged that, under the American Health Care Act, insurers could discriminate between the healthy and sick ― in some cases, by charging people with pre-existing conditions higher premiums.
This was OK, Brooks went on to explain, because that would mean lower premiums for healthy people who “have done the things to keep their bodies healthy … who have done things the right way.”
Brooks then recognized that some people have medical problems “through no fault of their own” and that society should take care of them, although he didn’t explain how to do that and suggested the matter was “complicated.”
Brooks may have been speaking for himself. Or he may have blurted out what many Republicans think but are loath to say explicitly ― that people with pre-existing conditions should pay more for their health insurance because in many cases their health status is a by-product of their behavior.
The assumption generated a furious backlash on social media ― and left one cancer patient, whom I first interviewed months ago, dumbfounded. “Tell me what in my lifestyle made me deserve to get this,” she said.
For the record, Brooks has a solid grasp of economics.
The basic challenge of any health care system is how to pay the bills of people with serious medical conditions. At any one time, those people comprise a small minority of the population but account for the vast majority of spending, since even a few people with conditions such as cancer can generate hundreds of thousands, or even millions, of dollars in medical bills.
Employer health insurance programs and, abroad, universal health care systems finance that care by spreading the burden as widely as possible so that everybody pays in equally, on the theory that everybody is at risk of serious medical expenses. The Affordable Care Act created a similar arrangement for people buying coverage on their own, by prohibiting insurers from charging higher premiums (or denying coverage) to people with serious medical problems.
Doing so made coverage available, at much cheaper rates, to people with pre-existing conditions. But it also raised premiums for some healthy people who could get cheaper coverage before Obamacare. That’s the main explanation for the “rate shock” that caused so much controversy when the law took full effect in 2014, and it has generated antipathy to the law since.
Republicans would like to undo these changes, in part or in whole, and then take care of people with special insurance plans ― so-called high-risk pools ― that traditionally offer less coverage with higher premiums, skimpier coverage or both.
That’s been the essence of pretty much every idea Republicans have floated for the past seven years, although they rarely admit it and sometimes try to deny it outright, as President Donald Trump did during an interview Monday with Bloomberg News.
“I want it to be good for sick people. It’s not in its final form right now,” Trump said, describing the American Health Care Act. “It will be every bit as good on pre-existing conditions as Obamacare,” the president said, apparently unaware of what the plan would actually do.
“Tell me what in my lifestyle made me deserve to get this.”
As for why people have pre-existing conditions ― and the role lifestyle choices play in them ― that’s a lot more complicated than Brooks and those who agree with him seem to realize.
Although the precise link between lifestyle choices and health status is fuzzy, the best available research suggests that behavior accounts for no more than half of existing health problems and most likely a lot less ― especially since “behavior” includes factors like obesity that, research has also shown, has a lot to do with environment, genetics and policy choices.
One person who knows how little health sometimes has to do with behavior is Maryann Hammers, a 61-year-old freelance journalist in Southern California. Hammers has been battling ovarian cancer for 3½ years. She’s been a vegan since age 18 and has always been a fitness freak. She never smoked or did drugs, and she exercised regularly even after the cancer treatments began.
When I met her a few months ago, at a coffee shop near her home, she was trim and dressed in athletic gear ― fresh off one of her regular walks in the hills.
At the time, Hammers said she was “terrified” about health care repeal. She depended on a subsidized insurance plan, which Obamacare made available, to pay for her cancer treatment. She was particularly worried because blood tests had recently detected higher levels of a protein associated with tumors.
On Monday, I emailed Hammers to get her reaction to Brooks’ comments. She called me back from her hospital room at City of Hope, a Southern California cancer hospital, where she has been recovering from surgery to remove three new tumors.
Hammers said she appreciated that Brooks at least recognized some people aren’t responsible for their own health problems. But when it came to his generalization that people in good health “have done things the right way,” entitling them to lower health insurance premiums, she found those comments “mind-boggling” and “arrogant.”
“My whole life … before and during cancer treatment, I have exercised more than anybody I know,” Hammers said. “I don’t know anybody my age as fit as I am, who can walk up a hill faster, who can walk up further.”
Hammers says that Brooks has a “blame the victim” mentality and was drawing an artificial distinction between the healthy and sick.
“He’s saying, ‘why should we make healthy people pay more, shouldn’t they get to pay less?’ Well, guess what? Everybody is healthy until they get sick.”
“I was the healthiest person on earth,” Hammers said, “until I wasn’t.”
Here’s Brooks’ full quote, taken from the video and a transcript by Talking Points Memo:
My understanding is that it will allow insurance companies to require people who have higher health care costs to contribute more to the insurance pool that helps offset all these costs, thereby reducing the cost to those people who lead good lives, they’re healthy, they have done the things to keep their bodies healthy, and right now those are the people who have done things the right way and are seeing their costs skyrocket.
Now in fairness, a lot of these people with pre-existing conditions, they have those conditions through no fault of their own, and I think our society under those circumstances needs to help. The challenge, though, is that it’s a tough balancing act between the higher cost of these mandates, which denies people coverage because they can’t afford the health insurance policies anymore on the one hand, and having enough coverage to help those people who are truly in need, and it’s a very complicated question, and I’m sure over the years there will be different permutations of it, both in the past and as we go forward.