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A health care proposal suggested by Republican vice presidential candidate JD Vance could gut a popular Affordable Care Act protection, making it legal for companies to charge more for or deny coverage of expensive medical conditions, including pregnancy.

Speaking at a Wednesday event in North Carolina, Vance said that if elected, former President Donald Trump would change health insurance regulations so that people who are healthier and use their insurance less can have cheaper coverage, while those with chronic conditions or who use health care more would have different insurance.

“That’s the biggest and most important thing that we have to change,” Vance said. 

The Ohio senator made similar remarks in a Sunday interview. In last week’s presidential debate, Trump said he had “concepts of a plan” to replace the Affordable Care Act, which expanded insurance to millions of Americans and instituted new consumer protections, including prohibiting health insurance from discriminating against people with preexisting medical conditions.

Vance has said that Trump would maintain those protections. But putting people in different insurance plans based on their health care would effectively undo them. The 2010 law created a single health insurance risk pool, so that people who use less health care effectively subsidize those who might need more — and beneficiaries pay the same premiums and deductibles.

Creating separate risk pools, as Vance suggested, would likely result in far less affordable insurance options for people who are sicker or have more medical conditions. Unless the federal government provides massive subsidies for people in the health plan targeted toward people who use their insurance more frequently, that coverage could be prohibitively expensive.

Vance has not specified if a new Trump administration would push to include subsidies, and the Trump campaign did not respond to a request for more details. It’s also not clear how this would cohere with other promises Trump has made, such as requiring health insurance to cover in vitro fertilization, an expensive medical service that not everyone uses. 

If enacted, a plan like this could have stark implications, undoing one of the Affordable Care Act’s signature benefits and making health care particularly more expensive for women and transgender people.

“What JD Vance is talking about is a very substantive change that would be a complete replacement of the ACA, and would look much more similar to what coverage looked like before,” said Cynthia Cox, a vice president at KFF, a nonprofit health policy research, polling and journalism organization. 

The proposal — based on the few details Trump and Vance have offered — could particularly affect people who can become pregnant. Before the Affordable Care Act took effect, health insurance plans were not required to cover pregnancy-related health care, which can be incredibly expensive, involving multiple doctors’ visits, medical tests, and labor and delivery itself. 

Creating tiers of insurance risk pools would mean people who either might become pregnant or who are pregnant might need to buy separate insurance that would cost more, because it is targeted toward people who use more medical care. Insurance that covered pregnancy could also come with other deterrents — long wait times or very high deductibles — that would make it functionally far more difficult to use. 

Even with comprehensive insurance coverage, pregnancy-related health care is already expensive. A 2022 analysis from KFF found that people with employer-sponsored health insurance — typically the most generous form of private coverage — paid on average almost $3,000 out of pocket when they give birth. The total cost, including what insurance paid, was just shy of $19,000. Depending on how Vance’s proposal were to be implemented, those costs could be passed back to patients. Since the ACA’s implementation, multiple studies have found that women are less likely to forego health care because of cost, and are in general spending less out of pocket on medical needs.

Prior to the ACA’s enactment, health plans could also deem being transgender as a preexisting condition, and would charge trans beneficiaries more for health insurance as a result. 

Women largely use more health care and as a result cost more to insure, because they are more likely to use services like contraception, go to “well woman” health care visits and require certain cancer screenings. Because of that, women used to pay more for health insurance in general before it was outlawed by the Affordable Care Act.

“There’s a lot in the ACA that certainly benefits women and it’s not clear whether that would stay or go,” Cox said.

The politics of enacting Vance’s proposal are dicey at best. In 2017, Republicans repeatedly tried and failed to repeal the Affordable Care Act. Those efforts led to widespread GOP losses in the 2018 midterm elections. Now, more than 60 percent of Americans say they support the health law, in large part thanks to its protections for people with preexisting conditions.  

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