Vance floats new health plans for chronically ill, reopening ACA debate

Sen. JD Vance (R-Ohio) this week said the Trump campaign wants to roll back the Affordable Care Act’s approach to how chronically ill Americans shop for health insurance, with the Republican vice-presidential candidate reopening a health-care debate that Democrats are eager to have — and resurrecting a fight that has repeatedly burned the GOP.

Speaking in North Carolina on Wednesday, Vance floated an idea to group chronically ill patients together in health-insurance pools based on their elevated risks. That would reverse a shift driven by the Affordable Care Act, which largely ended the practice of shunting chronically ill patients into what are known as high-risk pools and provided new protections for patients with preexisting conditions.

“We’re gonna actually implement some regulatory reform in the health-care system that allows people to choose a health-care plan that works for them,” Vance vowed, expanding on remarks he first made Sunday on NBC’s “Meet the Press.” The Ohio senator added that the Trump campaign wants to “allow people with similar health situations to be in the same risk pools,” so healthy patients would be able to obtain a different insurance plan than patients who are chronically ill.

Experts said the ideas sketched out by Vance threaten consumer protections enshrined in the 2010 health law, such as rules that guarantee health coverage to the tens of millions of Americans with preexisting conditions.

“I feel like I’ve been transported back to 2009,” said Adrianna McIntyre, a Harvard University health professor who has studied health insurance markets. “Prior to the Affordable Care Act, a number of states had these high-risk pools, and in general, they were hard for people to access.”

Vance’s comments were quickly amplified by the Harris campaign, which has sought to draw a distinction between Vice President Kamala Harris’s promise to build on the Affordable Care Act and rival Donald Trump’s repeated efforts to overturn the law when he served as president. The new remarks follow Trump’s admission in last week’s presidential debate that he has “concepts of a plan” to replace the Affordable Care Act — a vague pledge that Democrats have been eager to fill in, with Vance’s help this week.

“There should be no doubt about Donald Trump’s commitment to end the Affordable Care Act,” Harris campaign spokesman Joseph Costello said in a statement. “Now, one of the ‘concepts’ he’s bringing back is his plan to rip away protections for pre-existing conditions, throw millions off their health care, and drive up costs for millions of Americans with pre-existing conditions.”

Trump-Vance campaign aides have insisted that the GOP ticket would preserve protections for preexisting conditions, and a Vance spokesman said the candidate was not proposing new ideas in his remarks this week.

“Senator Vance was simply talking about the significant improvements President Trump made to the Affordable Care Act through his deregulatory approach, which aimed to bring down the cost of premiums while ensuring coverage for pre-existing conditions,” spokesman William Martin wrote in a text message.

The Trump campaign said Vance and Trump are aligned on key health-care goals.

“Senator Vance and President Trump share the underlying principles of using more choice in the marketplace and efficiency as tools for better, more affordable health care,” Brian Hughes, a senior adviser to the Trump campaign, said in a statement.

More voters side with Democrats on questions related to health-care costs and coverage, according to surveys by KFF, a nonprofit health policy research, polling and news organization. A KFF poll released this month found that 48 percent of voters trust Harris to do a better job than Trump on handling health-care costs, compared with 39 percent who favor Trump. The nine-point edge is one of Harris’s strongest advantages compared with Trump, who retains double-digit polling leads on the economy and immigration.

Democrats are keen to focus on the Affordable Care Act after it proved to be politically potent in recent election cycles. Republicans suffered major defeats in the 2018 midterm elections after their failed attempts a year earlier to repeal the law, and Joe Biden repeatedly pledged to protect it in his successful 2020 presidential campaign.

“I’m sure that the Democrats today would be very happy to have this conversation again,” said Mollyann Brodie, a KFF executive vice president who oversees the organization’s polling operation. “What we know from the polling is that Democrats do have an advantage on health care … and there are some political risks for the Republicans to try to take that on.”

The Harris campaign had already scheduled a week of events focused on Trump’s debate comments and past record on health care, with the vice president and her allies repeatedly warning voters that a second Trump administration could put their health care at risk.

As president, Trump repeatedly pushed for repeal of the Affordable Care Act and took other steps to weaken the law, such as curtailing funding spent on outreach and enrollment assistance. Trump said in last week’s debate that he would run the Affordable Care Act “as good it as it can be run” if elected president again.

Protect Our Care, a Democrat-aligned health-care advocacy group, next week plans to launch a nationwide bus tour of battleground states to contrast Trump’s health-care actions with the Biden administration’s efforts to strengthen the Affordable Care Act.

Vance’s comments center on a concept that shaped the U.S. health system for decades: Patients were evaluated on their individual risks, meaning they could be charged different amounts for their health insurance based on whether they had preexisting conditions. As a result, chronically ill patients said they faced staggeringly high health insurance premiums and other barriers that made it difficult to pay their bills or get covered at all.

The Affordable Care Act imposed restrictions on private health insurers, limiting how much the plans could charge patients based on age and other factors, and barring health plans from turning away patients who had preexisting conditions. Because of those changes, the health insurance market was significantly revamped; young and healthy patients now subsidize the cost of health insurance for older, chronically ill patients, with federal subsidies also underpinning the market’s operations.

Ending the Affordable Care Act’s approach to pooling health insurance risk could lead to cheaper health plans for younger Americans, but more expensive plans for older Americans, experts said.

“High-risk pools arise out of a situation where you don’t have protections for preexisting conditions,” Harvard’s McIntyre said. “Now, hypothetically, you could have incredibly well-funded high-risk pools, but that’s not necessarily going to be less expensive than the system we have now.”

Conservatives have repeatedly pushed for alternatives to the Affordable Care Act’s rules. A proposal released by the House Republican Study Committee this year argued that Maine devised a successful risk-pool system in 2011 that could become a national model.

“Providing all states the freedom to adopt these smart reforms would significantly increase access to private health insurance, reduce costs and reduce federal spending,” the influential House GOP group argued.

Jeanne Lambrew, a Democrat who served as Maine’s health commissioner between 2019 and 2024, said she was skeptical that her state’s high-risk pool could be a national model. Maine ultimately did away with its high-risk pool in 2022, merging its insurance markets.

“While it may have had some value pre-ACA … post-ACA, the marginal value was not just low, but rejected by a unanimous, bipartisan majority in the legislature,” said Lambrew, who helped implement the Affordable Care Act in the Obama White House.

Laura Packard, who was diagnosed with Stage 4 cancer in 2017 and serves as executive director of Health Care Voter, a left-leaning advocacy organization, said she worries about the impact of returning to a pre-Affordable Care Act system for potentially “uninsurable” patients like she once was.

“I am in remission now, but no insurance company if ever given the choice to choose their customers would ever choose to cover me at a price I could afford,” Packard said. “If we go back to the days of high-risk pools, that’s not going to work for anybody that really needs their health care.”

Vance, who was elected to the Senate in 2022, has not served on one of the key health-care committees, and his record on health care is limited. He has been a longtime critic of the Affordable Care Act, writing in a 2010 letter to the editor in the Journal-News newspaper in Ohio that “Obama-Care does nothing to reduce the inflationary trend of medical costs, it is an abject failure of a reform package. That’s why most conservatives opposed it.”

But before assuming office, Vance had criticized GOP efforts to repeal and replace the Affordable Care Act as insufficient, noting that the party’s alternative bills were projected to provide health coverage to far fewer people.

Republicans’ attempt to do away with the Affordable Care Act under Trump “was genuinely a moral and political disaster,” Vance said in 2019 remarks, criticizing former House Speaker Paul D. Ryan and colleagues’ legislation. “I’m glad that it never passed.”

While running for Senate in 2022, Vance said Republicans had to offer an alternative to the Affordable Care Act with “some substance to it, or we are going to get creamed electorally and we’re not actually going to do that job that the people sent us to do,” the Chronicle newspaper in Northeast Ohio reported at the time.

Brodie, the KFF pollster, said there’s an opportunity for politicians — including Republicans — to revisit questions about health coverage, if they tread carefully.

“People of all stripes are really frustrated about their health-care costs,” Brodie said. “You could see somebody trying to thread a needle of tapping into that frustration … the challenge is they need some sort of plan, or credible messaging, that their proposal really would help people afford the health care that they want and need.”

But few Americans trust that Trump, who spent nearly a decade pledging to “repeal Obamacare” and continues to discuss overhauling the law, has a concrete plan to do so. Only one-third of self-identified “MAGA” supporters — and 16 percent of all Americans — believed that Trump had a plan to replace the Affordable Care Act, according to a KFF poll released in February.

Lambrew, the former Obama health official, said Vance’s recent remarks are “déjà vu” and recall the Affordable Care Act repeal fight.

“JD Vance’s return to these ideas is a signal that we’re talking about the same type of ideas that we saw in 2017,” Lambrew said. “It’s a signal of what may be the future under this president.”