Tight Iowa congressional races key on pre-existing condition protections

The battle over keeping the Affordable Care Act's strong insurance protections for people with pre-existing medical conditions has surged to the center of tight House and Senate contests across the country.

But the issue has become particularly heated in two toss-up House races in Iowa. Unregulated Farm Bureau health plans will go on sale Nov. 1, and they can consider pre-existing conditions under a new state law. It's expected that some Iowans applying for the cheaper Farm Bureau plans will get turned down or will be quoted higher rates based on their health status. That could raise the stakes for voters.

If Democratic challengers Cindy Axne and Abby Finkenauer can ride the pre-existing condition issue to upset victories over Iowa Republican incumbents David Young and Rod Blum, that could help their party capture control of the House. Then Democrats are likely to push legislation to preserve and strengthen the Affordable Care Act's consumer safeguards.

Across the country, Democratic ads for federal races in September concentrated on healthcare, with half mentioning the subject and 10% explicitly defending the ACA or attacking GOP efforts to repeal the law's protections, according to the Wesleyan Media Project. A recent Morning Consult-Politico poll found that 81% of voters think it should be illegal for insurers to deny coverage based on health status.

"Pre-existing condition protections have become a potent issue for Democrats, bringing broad bipartisan support and a reminder of Republican political and legal efforts to roll them back," said Larry Levitt, senior vice president at the Kaiser Family Foundation.

The overall issue of healthcare is especially high-profile in the Hawkeye state because Republican Gov. Kim Reynolds and Democratic challenger Fred Hubbell are battling fiercely over former Republican Gov. Terry Branstad's controversial handoff of Medicaid to private managed care companies two years ago.

If Hubbell wins the close race and Democrats win control of the legislature, they could roll back the Medicaid privatization program and erase the Farm Bureau health plan law, said Arthur Sanders, a political science professor at Drake University in Des Moines, Iowa.

"If you look at the polls, Medicaid privatization is a winning issue for Democratic candidates for state office," Sanders said. "To the extent that issue brings voters to the polls, those same voters almost certainly have decided the Democratic congressional candidates have better positions on healthcare."

Two-term congressman Young is locked in a close race with Democratic technology consultant Axne for the 3rd congressional district seat representing the Des Moines area. Blum, also in his second term, is facing off against state lawmaker Finkenauer for the 1st congressional district seat representing the Cedar Rapids and Dubuque areas.

The two Republican congressmen have been forced to defend their votes last year for the GOP-sponsored American Health Care Act and other ACA repeal bills, which would have repealed and replaced the ACA and let states reinstate the use of medical underwriting by insurers.

Young touts his co-sponsorship of an amendment to the AHCA that added $8 billion in funding over five years to prevent big premium hikes for patients with pre-existing conditions. "David stood up to his party to protect Iowans with disabilities and pre-existing conditions," a Young TV ad boasts.

Firing back, an Axne TV spot says that while Young claims he has fought for people with pre-existing conditions, "he is lying to hide the fact that… he voted with insurance companies to gut protections for the 50% of Iowans under 65 with pre-existing conditions."

In an interview, Axne said nearly one million Iowans have pre-existing conditions and "it's an incredibly important issue to make sure all those people have coverage." Given the high premiums and limited insurance competition in Iowa, she also wants to offer consumers a public health plan option.

Young's campaign did not respond to requests for comment.

Blum's campaign highlights that the AHCA bill he supported barred insurers from denying coverage based on health status.

At the same time, however, it allowed states to opt out of the ACA rule prohibiting insurers from charging higher premiums for people with pre-existing conditions.

While the two Republicans argue they strongly support protections for people with pre-existing conditions, many experts say nothing in the AHCA bill would have guaranteed access to affordable coverage for people with pre-existing conditions. On top of that, some GOP leaders, including Vice President Mike Pence, have promised to give ACA repeal another shot next year if their party keeps control of Congress.

"It'd be hard to find a candidate these days willing to say they oppose pre-existing condition protections," Levitt said. "But whether they support the regulation and money to make it a reality is a different question."

Meanwhile, some experts worry that the new, cheaper Iowa Farm Bureau plans allowed under a state law passed by the GOP-controlled legislature earlier this year will siphon off healthier people and drive up rates for ACA-compliant plans that must accept everyone regardless of health status. Tennessee is the only other state that allows medically underwritten Farm Bureau plans.

"It could leave middle-income, unsubsidized people with pre-existing conditions who couldn't get a Farm Bureau plan paying a lot more than they otherwise would," said Sarah Lueck, a senior analyst at the liberal Center on Budget and Policy Priorities.

The Iowa Farm Bureau plans will be administered by Wellmark Blue Cross and Blue Shield but won't be considered health insurance under state law and won't be regulated by the Iowa Insurance Division. The companies have not yet indicated whether or how people with pre-existing conditions will be accepted for coverage, or how rates will be set.

They will be available to anyone who buys a $55 Farm Bureau membership, whether they work in agriculture or not.

A Farm Bureau spokeswoman said her company's plans, which will cover most ACA essential benefits, "will most likely provide a more affordable option" than ACA plans for people who don't qualify for ACA premium subsidies. She didn't respond to questions about access for people with pre-existing conditions, other than to say the plan "will not be the right fit for everyone."

Even Iowa insurance brokers who will be selling Farm Bureau plans say they don't yet know how the plans will work. They're watching nervously.

"With the ACA, people are used to pre-existing conditions not being a problem, and that's hard to go back on," said Stan W. Reynolds, vice president at the Reynolds & Reynolds insurance agency in Des Moines. "I can't imagine a politician running on taking away that part, no matter what party."