September 29, 2015

The Pre-existing Condition: Innovative Solutions to America’s Thorniest Healthcare Challenge

Additional details

This book is available as an ebook and paperback for purchase at

Perhaps the most difficult challenges in healthcare policy is how to ensure that individuals with pre-existing medical conditions have access to the care they need without facing ruinous costs. The Patient Protection and Affordable Care Act (ACA) sought to find a solution in a vast, complex apparatus of individual and employer coverage mandates, guaranteed access to insurance for everyone, prohibitions against insurers charging the expected cost of insurance, requirements that some participants subsidize others, and hundreds of other provisions. In effect, the ACA sought to provide support for individuals with high healthcare costs by forcing other participants in the health insurance market to pay far more than their own insurance was worth to them. As predicted by many experts across the political spectrum, the ACA’s controversial approach resulted in most affected Americans getting a worse deal on their health insurance. 

As they craft a plan to repeal and replace the ACA that relieves Americans of these burdens, Congress and the Trump administration must still determine how to protect those facing expensive health conditions. Ideally, their solutions will be more equitable, more transparent, and less burdensome and bureaucratic than the ACA. 

In 2015, the Mercatus Center at George Mason University commissioned a set of essays in which leading policy experts shared innovative ideas on how to solve the pre-existing condition challenge. While their approaches exhibit differences, several themes recur throughout the series: 

  • Address problems created long before the ACA by the tax preference for employer-sponsored insurance. 
  • Policymakers should set clear, limited objectives that reflect what insurance can reasonably do. 
  • The government’s healthcare policy should establish incentives for individuals to maintain continuous coverage and protections for those who do, regardless of their health status.
  • The government could subsidize those facing high healthcare costs through mechanisms such as high-risk pools. 
  • Healthcare policy should promote broader healthcare quality improvements and enable a vibrant healthcare market. 


  • The best alternative to the individual mandate is technological innovation that makes people ask why on earth anyone ever thought a mandate was necessary.

    Robert Graboyes
    September 29, 2015
  • There is nothing about markets for health insurance that requires a mandate-heavy, regulatory approach to solving the problem of pre-existing conditions. A better approach uses high-risk insurance pools to address pre-existing conditions in the current population and continuous insurance coverage to address pre-existing conditions in the future.

    Douglas Holtz-Eakin
    September 29, 2015
  • In the wake of calls to repeal the ACA, anyone with a pre-existing condition (or who may develop one) is right to ask: If I take steps to make responsible choices, will I be denied health coverage at any time because of a medical condition? Will my premiums be fair, or will they be significantly higher than my peers’?

    September 29, 2015
  • Guaranteed-renewable insurance allows those with chronic health conditions to pay a pooled premium that is the same as that paid by those without chronic health conditions, but as a result of a voluntary decision to pool together rather than a regulatory requirement to do so.

    Bradley Herring
    September 29, 2015
  • We ought to focus on protecting people from the risk we know they face—catastrophic medical bills—by deploying our endless talent for innovation through markets rather than our decidedly lesser talent for creating and managing massive regulatory bureaucracies.

    September 29, 2015
  • People who stay continuously covered by health insurance could be protected from their health status factoring into the premiums they owe or the coverage they can secure: this would allow consumers to move seamlessly between insurance platforms without fear of being penalized financially based on their medical history.

    James C. Capretta
    September 29, 2015
  • The ACA’s comprehensive insurance mandate is an example of legislative overkill in response to a policy challenge. That challenge is to protect Americans from financial hardship arising from high individual healthcare costs. This risk protection function need not necessarily be mixed with other compelling policy agendas such as broader income support goals and which healthcare services Americans should receive.

    Charles Blahous
    September 29, 2015