President Trump is promising again  to release a comprehensive health care plan to replace the Affordable Care Act. If he actually keeps that promise, what would it be likely to provide?
At this point, most of the details of the president’s plan are not public. Nevertheless, there are three things that we already know for sure. First, a Trump health plan would promise to protect people who have pre-existing medical conditions, but it would not really achieve that. Second, it would sacrifice the quality of benefits and level of coverage in most health insurance policies, as ways to lower insurance premiums. Third, it would make existing health disparities in the U.S. even worse.
The president has recognized the political necessity of protecting (or at least claiming to protect) people who have pre-existing conditions, and he has repeatedly promised to do so . He recently indicated that he might issue an executive order on pre-existing conditions as “a signal to people .” The reality, though, is starkly different.
What if the president’s plan includes an explicit statement in a proposed federal law that would require all insurance companies to sell policies to everyone, regardless of any pre-existing condition? And what if the proposed law would also require insurance companies to treat everyone equally, and prohibit discrimination on the basis of medical condition in the extent of coverage or amount of premiums?
Unfortunately, those provisions would not be sufficient to protect people who have pre-existing conditions. Here’s why:
Although treating people equally may appear on the surface to be fair, people who have pre-existing conditions have very different needs in health insurance coverage. The devil, as the saying goes, is in the details.
Most healthy people, for example, would not be adversely affected by restrictions in insurance policies such as annual or lifetime caps on benefits, exclusion of coverage for specific illnesses, or refusal to pay for very expensive treatments or drugs. If, however, an insurance policy provides only those benefits that are needed by people who are generally healthy, people who have pre-existing conditions could be ruined financially and deprived of access to lifesaving medical care.
In addition to not protecting people with pre-existing conditions, a Trump health plan would lower the quality of benefits and level of coverage in most insurance policies. Insurance coverage would be “cheap” both in the sense of “inexpensive” and in the sense of “inferior” or “shoddy.”
Almost any product or service can be reduced in price by reducing its quality. People might be tempted to purchase a less expensive version, until they realize what they would be giving up in terms of quality and safety. In health insurance, quality includes criteria such as amount of coverage, scope of benefits, and freedom to choose a health care provider. If a person buys a cheap health insurance policy, that person (or that person’s spouse or child) might not have enough insurance coverage to afford medically necessary drugs or treatments.
Finally, a Trump health plan would exacerbate existing health disparities in the U.S.. As a practical matter, lowering the quality of health insurance for most Americans would encourage wealthy people to buy more expensive health insurance. Wealthy people and their families would have a higher level of coverage, a broader range of benefits, and more flexibility to choose their doctors and hospitals.
We already have severe health disparities in the U.S. on the basis of race, ethnicity, gender, income and other factors. For example, Black people have a shorter life expectancy  and a much higher rate of infant mortality  than whites. The COVID-19 pandemic in the U.S. has resulted in additional disparities, because Black and Latinx people have higher rates of infection and higher rates of death  from COVID-19 as compared to white people. By reducing the quality of health insurance coverage for most Americans and indirectly encouraging rich people to get better insurance, a Trump health plan would solidify two levels of care in the U.S.— one for the rich and one for everybody else.
By the way, there already is a health plan that protects people with preexisting conditions, provides comprehensive coverage with high standards of quality, and takes important steps toward reducing health disparities. It’s called the Affordable Care Act.
Dean M. Harris, an attorney, retired from the faculty at UNC-Chapel Hill’s Gillings School of Global Public Health, where he taught health law for more than 25 years.