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Star Tribune

Type 2 diabetes. Sleep apnea. Obesity. Coronary artery disease. Mental illness. These are just a few of what used to be known as “declinable conditions” before the Affordable Care Act (ACA) passed in 2010.

If you had one of them and had to buy health coverage on your own because you were self-employed, retired early or lost your job, insurers could simply reject your application for coverage. Or, if they did sign you up, exclude treatment costs for them.

Note how common many of these are. Overall, 27 percent of American adults under age 65 have what was once considered a declinable condition, according to a Kaiser Family Foundation report. The number rises to 44 percent for adults age 55-64. The vast number of Americans with one or more of these conditions is a key reason why the ACA’s coverage protections are one of law’s most popular provisions.

With the November election looming, voters can expect to hear candidates from both political parties pledging to protect these safeguards even as the law’s fate hinges on yet another legal challenge.

Those vows are welcome, but they merit scrutiny. There’s a big difference between promising to keep these protections and actually doing it. Careful, interlocking insurance regulations are needed at the same time to keep coverage affordable and prevent individuals from gaming the system, such as only signing up for coverage when they get sick. “You can’t just sprinkle magic pixie dust and declare it done,” said Larry Levitt, executive vice president for health policy with the Kaiser Family Foundation.

Levitt, who has a large Twitter following, posts periodic reminders about the complexities. If doing so were easy, Levitt said in an interview with an editorial writer this week, pre-existing condition protections would have been in place long before the ACA’s passage a decade ago.

The landmark health reform is again facing an uncertain future, with the U.S. Supreme Court slated later this year to begin weighing a lawsuit that seeks to overturn the entire law. The U.S. Justice Department has joined the effort to strike down the ACA.

If this happens, the law’s pre-existing conditions protections evaporate and so do many other helpful measures, such as financial assistance to buy insurance, benefit requirements and the ban on lifetime coverage limits. While it’s not immediately intuitive, the law’s components worked interactively to ensure that people with declinable conditions could get coverage and afford it and that it would meet their medical needs.

A simplistic mandate that insurers must cover pre-existing conditions won’t suffice if the law is overturned. One concern, previously mentioned, is that individuals wait until they’re sick to sign up for coverage. Candidates promising protections should be asked how they will prevent this, otherwise no one will sign up for coverage until they become ill, undermining the insurance market.

Another critical concern: those with a pre-existing condition will simply be priced out of the market. Insurers could offer plans but make them prohibitively expensive for those who have ongoing medical concerns.

Levitt also warned of problems that could start lurking again in a plan’s fine print. There could be limits placed on coverage that someone with a serious medical condition might exceed.

Don’t let politicians off the hook easily on this important issue this fall, Levitt said. “If a candidate says they want to protect people with pre-existing conditions, look behind the what they’re staying to see if they’re willing to put in place the regulations and spend the money to make it a reality.”