Will Republicans keep their new promises on pre-existing condition protections?

With their increasingly ardent campaign promises to protect health coverage for people with pre-existing medical conditions, House and Senate Republican candidates will face pressure to keep those commitments if they win in November.

GOP leaders, including Vice President Mike Pence, say they want to try again in 2019 to repeal the Affordable Care Act. Last year's GOP repeal bills would have significantly weakened the law's provisions, letting states re-establish the use of medical underwriting by insurers.

Despite the candidates' promises, both Republicans and Democratic health policy analysts doubt whether victorious Republicans would move to replace those ACA protections with equally strong measures to cover people with health conditions as part of repeal legislation.

"That could be a big split among Republicans," said Rodney Whitlock, vice president of health policy for ML Strategies and a former Senate Republican staffer.

"I wouldn't read much into these statements other than just more smoke and mirrors," said Billy Wynne, CEO of the Wynne Health Group and a former Democratic Senate staffer.

On Wednesday, Senate Majority Leader Mitch McConnell (R-Ky.) signaled interest in giving ACA repeal another go. "If we had the votes to completely start over, we'd do it," he told Reuters. "We're not satisfied with the way Obamacare is working."

The courts also could force the issue. A pending federal lawsuit in Texas brought by 20 Republican attorneys general and supported by the Trump administration seeks to strike down the ACA as unconstitutional. The conservative judge hearing the case is thought likely to side with the plaintiffs, and soon, though any decision is certain to be appealed.

Yet numerous GOP candidates have made seemingly ironclad pledges to keep the ACA's highly popular protections for people with pre-existing conditions. Those include provisions requiring insurers to accept applicants and set premiums without regard to pre-existing conditions, cover those pre-existing conditions, and set no annual or lifetime benefit caps.

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.

Some GOP analysts say their party's lawmakers, if they keep control of Congress, may find themselves boxed in by their own campaign rhetoric. They will have to do a better job than they did in 2017, they say, of assuring Americans they have a viable alternative system for covering people with pre-existing conditions.

"The members are so far out on this now, they're going to be under pressure to do something more federally overt than just say, 'We'll trust the states to do this right,'" Whitlock said. "From now until Nov. 6, they have to constantly tell people they really do care about pre-existing conditions. But after that, they have to deliver on policies."

Republicans are in this tough position because they failed last year to effectively present market-based mechanisms for ensuring access to coverage, said Thomas Miller, a conservative health policy scholar at the American Enterprise Institute.

"They are reaping the whirlwind of not being sure what they believed in, not articulating it in a better manner, and not ponying up the money earlier for the necessary subsidies," he said.

Responding to attacks by their Democratic opponents on the pre-existing condition issue, many GOP candidates—including those who previously sought to loosen or eliminate the ACA rules—have come out strongly in favor of consumer protections.

"I support forcing insurance companies to cover all pre-existing conditions," Missouri Republican Senate candidate Josh Hawley says in a TV ad —even though he's one of the Republican attorneys general seeking to overturn the ACA in the Texas lawsuit.

"We cannot go back to where we were before Obamacare, where people were one diagnosis away from going bankrupt, because they could not get access to healthcare," said Republican Rep. Martha McSally, who's running for an Arizona Senate seat. She voted last year for a House bill allowing states to give insurers leeway to charge higher premiums to people with pre-existing conditions.

Not surprisingly, their Democratic opponents call them liars, while nonpartisan experts use slightly milder language.

"If you're in a tight election with a record of promoting something unpopular, you can admit it and say it's the right thing to do, you can confess error and say you'll never do it again, or you can lie," said Norman Ornstein, a congressional scholar at the American Enterprise Institute. "Republicans are taking the third option."

Some Senate candidates point to their support for a bill sponsored by North Carolina Sen. Tom Tillis that would bar insurers in the individual market from denying coverage to people with pre-existing conditions or setting premiums based on health status.

But the bill would permit carriers to exclude coverage for pre-existing conditions, and would allow rate-setting based on age, sex, occupation, and lifestyle. Independent experts see those as loopholes that would render the bill's protections largely meaningless.

If Democrats gain control of at least one chamber of Congress, the most likely post-election scenario is for congressional Republicans to support continued moves by the Trump administration to establish leaner, cheaper health plans that don't have to comply with the ACA's pre-existing condition protections.

Whitlock acknowledged that could call into question Republicans' commitment to preserving affordable coverage for the millions of Americans with health conditions. "That's going to be a challenge to show how the marketplace can remain healthy if you are allowing people who feel they don't need those protections to exit," he said.

Ornstein believes that losing control of the House while keeping their Senate majority would give Republicans the best of both worlds politically on health policy. "They can satisfy their base by railing against the horrible Obamacare system, without having to take the consequences of snatching protection away in front of people's eyes," he said.