Misinformation abounds, from tales that people who talk to contact tracers will be sent to nonexistent "FEMA camps"

This article was first published on Wednesday, July 15, 2020 in Kaiser Health News.

By Julie Appleby July 15, 2020

In the midst of the COVID-19 epidemic, contact tracing is downright buzzy, and not always in a good way.

Contact tracing is the public health practice of informing people when they've been exposed to a contagious disease. As it has become more widely employed across the country, it has also become mired in modern political polarization and conspiracy theories.

Misinformation abounds, from tales that people who talk to contact tracers will be sent to nonexistent "FEMA camps" — a rumor so prevalent that health officials in Washington state had to put out a statement in May debunking it — to elaborate theories that the efforts are somehow part of a plot by global elites, such as the Clinton Foundation, Bill Gates or George Soros.

At the very least, such misinformation could hinder efforts to contain the virus, and at worst has sparked threats against tracers, say some observers, including the Institute for Strategic Dialogue (ISD), a London-based organization that studies polarization.

The dynamic, ISD notes in a June report, "is being generated both by individual social media users and by key influencers in conspiratorial communities" and plays on fears that Big Brother is watching us.

According to that report, social media posts, mainly videos, have been associated with "widespread sharing of petitions and other efforts to galvanise political action against contact tracing." The videos, steeped in disinformation and conspiracy think — whether alleging tracers' ties to the deep state or casting them as part of a Democratic effort to interfere in the 2020 election — "are receiving more than 300,000 views each on YouTube and are being shared tens of thousands of times across public Facebook pages and groups."

Of course, the real story behind tracing is nothing like these colorful conspiracy theories. It's an age-old infection control strategy, and it's a bit tedious, actually.

"We've been doing it in public health for decades," said Marcus Plescia, chief medical officer for the Association of State and Territorial Health Officials.

Part old-fashioned shoe-leather detective work, part social work, the goal is to interrupt the spread of the illness by reaching out to people who test positive — and people they have been in close contact with — and provide needed support for them to isolate. It has to be done quickly, and it takes a lot of people. Recent case count surges in some parts of the country are making the task more difficult.

So let's take a look at what it is and isn't.

What's the Process?

When a person tests positive for certain communicable diseases, health care providers must report their contact information to public health departments. Contact tracers then try to reach out quickly, generally by phone.

The tracer will ask for the patient's address. Some social media sites have decried this as nefarious, but it's not. The tracer does not want to provide private medical information — "Mr. Smith, I see you tested positive for COVID" — to the wrong person. Those contacted should also feel free to confirm it really is the public health department calling, experts note, as there have been reports of fraudulent calls.

During the initial call, the tracer makes sure the patient is OK and understands the disease and what to expect. Ideally, the contract tracer builds a relationship with the patient. Some can link the patient with local resources or services, such as food delivery or needed medical supplies, that can make it easier to stay isolated until they have recovered from the virus.

What's a Close Contact?

Contact tracers ask where the infected person traveled and with whom they came in close contact — generally defined as being within 6 feet for 15 minutes or more — from about two days before they started showing symptoms until they isolated themselves.

That does not include such things as simply passing people on the street or opening the door to pick up a package dropped off by a FedEx driver.

Providing the information is voluntary, but it is the only way the programs will work. Most patients happily comply, but a few are reluctant, said Plescia.

"That was a little surprising," he said. "You would think if you might cause another person to become ill, you would have an interest in that person being notified. But some worry they are snitching on other people."

Tracers do not disclose the name of the infected person. Contacts simply "receive a call saying 'You have had a significant exposure,'" said Crystal Watson, senior scholar at the Johns Hopkins Center for Health Security and co-author of a report on contact tracing.

To assist with tracing, some restaurants, stores, salons and other businesses are keeping daily logs of customers. Some voices on social media have raised concerns about those logs, saying they are intrusive and suggest that Big Brother is watching. Their purpose, though, is to make it easier for health officials to notify other employees and patrons in the event that someone tests positive.

Close contacts are urged to quarantine for 14 days, check their temperature regularly and avoid contact with other household members, if possible.

For each infected patient, tracers need to contact an average of 10 other people, said Watson — noting, however, that the number could be far higher. "If contact tracing is done in a place where there's a big epidemic and no one is under social distancing restrictions, you'll have to contact more," she said.

Speed is of the essence in finding close contacts. Infected people start showing symptoms within two to seven days of exposure — although it can take up to 14 — and they may be contagious before symptoms appear.

Who Asks All of These Questions?

In the early days of the COVID pandemic in the U.S., tracing was limited because testing for the virus was also limited. The two really go together. That meant the nation used the other tool at its disposal, the blunt instrument of stay-at-home orders. Now, with testing more available, and with many states in the fits and starts of reopening, the more targeted effort of contact tracing becomes important.

Used effectively, it can sharply slow outbreaks, as seen in countries that have employed comprehensive tracing programs, such as Japan, New Zealand and China.

So far, though, the U.S. has a more limited effort, and it varies by state.

An estimated 37,000 contact tracers are now employed by public health departments nationwide, triple the number just a few weeks ago, according to an NPR state survey and tracking effort. Still, those numbers are far below estimates of what many say is necessary. Indeed, Watson and other Johns Hopkins researchers say the U.S. needs to add a minimum of 100,000 contract tracers.

Can They Force Me Into Quarantine?

Although health officials do have the authority to isolate people who pose a danger to others, that power is almost never used.

"Mandatory quarantine hasn't really been used since the days of smallpox in this country, although the president used it in the beginning of the pandemic for some people repatriating back to the county," said Watson.

Public health officials avoid such aggressive tactics because they don't want to discourage people from getting tested. As for hauling people away from their homes by force, that also doesn't happen here, although it does in some authoritarian countries. Instead, a number of cities and regions have set up special hotels or other facilities where infected or exposed people who live in homes where they can't isolate themselves from other family members can voluntarily spend their convalescence.

Is It Working?

It has certainly worked in other countries, said Howard Koh, professor at the Harvard T.H. Chan School of Public Health and former assistant secretary for health in the Obama administration.

"Italy, Spain, China, Taiwan, Hong Kong and New Zealand have all gotten to the other side of the curve," said Koh. "When they have outbreaks, they are relatively small and they jump on them right away."

One difference, he said, is those places have a national strategy.

"In our country, we have a 50-state strategy, a patchwork response including contact tracing, with some states having embraced it and some have barely started."

Massachusetts and New York have reported success with tracing, said Watson.

But there are many areas of the country, especially the Sun Belt, where cases are spiking, complicating efforts to control the virus. With more interest in getting tested, turnaround time for results grows. And large numbers of new cases mean contact tracers have far more people to track down, making it challenging to do so in the short time frame needed to be effective.

"I'm discouraged that a lot of the states where we are seeing a big surge right now have not put a lot of effort into developing their contact tracing workforce," Watson said, echoing Koh's call for a national plan. "We need an initiative by the federal government focused on contract tracing."

Julie Appleby: jappleby@kff.org, @Julie_Appleby

HHS secretary says preexisting conditions have the protections originally offered under HIPAA.

This article was first published on Tuesday, July 14, 2020 in Kaiser Health News.

By Julie Rovner July 14, 2020

One of the most popular features of the Affordable Care Act is its guarantee of insurance coverage — at no greater cost — for people with preexisting health conditions.

Thus, even as the Trump administration argues before the Supreme Court that the entire Affordable Care Act should be declared invalid, the president and his administration officials maintain that regardless of what happens to the ACA, they will protect people who have had health problems in the past.

Speaking to a "virtual health summit" sponsored by the political newspaper The Hill, Health and Human Services Secretary Alex Azar answered a question about the case, Texas v. Azar, by pointing out "it's in statute already in HIPAA that preexisting conditions are covered," implying that if the ACA were declared unconstitutional, those protections would remain in place for everyone.

Umm … not so much.

When we checked with HHS for more information about Azar's comment, a spokesperson reiterated the secretary's statement, adding that Azar was "clear that the story on preexisting conditions doesn't end with HIPAA" and that affordability is a critical component.

So we investigated.

A Little About HIPAA

The Health Insurance Portability and Accountability Act, a law we have examined before, was passed by a Republican-led Congress and signed by Democratic President Bill Clinton in 1996. It is best known for safeguarding medical privacy and patient access to medical records, even though the privacy provisions were added toward the end of congressional deliberations.

HIPAA's original purpose was to end what was known as "job lock," a situation in which people with preexisting conditions were reluctant to leave jobs with health insurance even for other positions with health insurance for fear their conditions would not be covered or they would be subject to long waiting periods for coverage. Both scenarios were common at the time.

HIPAA addressed that problem — as long as people maintained "continuous" coverage, defined as having health insurance for at least 12 months without a break of more than 63 days. People who met that requirement could not have waiting periods or denials of coverage imposed upon their own or a family member's preexisting condition. HIPAA included protections for people with coverage in the small-group insurance market, which primarily comprises small businesses, by requiring insurers who sold policies in that market to sell to all small groups, regardless of health status, and to cover every eligible member of the groups — again, regardless of health status.

But HIPAA was not designed to comprehensively address the problem of people with preexisting conditions getting and keeping affordable health insurance.

For starters, the protections were only for people who already had job-based insurance, to make it easier for them to move to other job-based insurance. It did nothing for those in the individual insurance market who needed to purchase their own coverage — such as self-employed people and those working for companies that did not offer health insurance.

HIPAA attempted to create a pathway for people transitioning from employer-sponsored to individual coverage. It ensured that, after leaving a job, people who secured insurance through another law, the 1986 Consolidated Omnibus Budget Reconciliation Act, or COBRA, would be eligible to buy a "conversion" plan from their insurer once their previous job-based benefits were exhausted.

However, two giant problems arose. First, COBRA, which allows individuals to continue their employer-provided coverage for up to 18 months if they pay the entire premium themselves (plus a small administrative fee), is prohibitively expensive for most people. In 2019, the average premium for a single worker was $599 per month.

The other problem was that even if a former worker did manage to pay for COBRA coverage until that 18-month period ended, there was no limit on how much insurers could charge for the conversion policies. So, even if they were technically available, they were frequently unaffordable.

There were other problems. COBRA coverage was not available to people who worked for small businesses, or for those who became unemployed because the business they worked for failed and no longer offered insurance to anyone. HIPAA also did not stipulate which benefits had to be offered.

Next, the ACA

Sources

Health Insurance Portability and Accountability Act of 1996 

Affordable Care Act of 2010 

Email exchange with a Department of Health and Human Services spokesperson, July 10, 2020

Email exchange with Timothy Jost, emeritus professor at Washington and Lee University School of Law in Virginia, July 10, 2020

Email exchange with Karen Pollitz, a senior fellow at KFF (the Kaiser Family Foundation; KHN is an editorially independent program of the foundation), July 10, 2020

"Trump Administration Asks Supreme Court to Strike Down Obamacare," The Washington Post, June 26, 2020

"Did The ACA Create Preexisting Condition Protections For People In Employer Plans?" May 21, 2019

The HIPAA Privacy Rule, Department of Health and Human Services, April 16, 2015

"Average Annual Single Premium per Enrolled Employee for Employer-Based Health Insurance," Kaiser Family Foundation, time frame 2018

The ACA sought to deal with HIPAA's shortcomings. It required most employers to offer coverage and, for those purchasing their own, it required insurers to provide a comprehensive package of benefits at the same price to all purchasers, regardless of health status.

However, the ACA rewrote the HIPAA provisions regarding preexisting conditions, so if the ACA is struck down by the Supreme Court, it's not clear whether even HIPAA's lesser provisions would remain. Experts disagree about this, but there is a possibility that HIPAA's protections could be swept away along with the ACA.

Later in his answer to the question posed at The Hill's summit, Azar pointed out that there are significant affordability problems with coverage under the ACA, as well. "So we will work with Congress if the time ever comes, to get real affordable solutions," he said. That's true. ACA plans, even with subsidies, can be too expensive for some people, and prohibitive for those who earn just slightly too much to qualify for government help. Earlier this month, Democrats in the House passed a bill to make ACA plans more affordable.

Our Ruling

Azar's statement suggested that if the Supreme Court rules against the ACA and that sweeping law is nullified, Americans with preexisting conditions would continue to have the protections originally offered under HIPAA.

Though it contains an element of truth, it leaves out critical pieces of information. For instance, the HIPAA protections are not equivalent to those provided by the ACA. First, they are geared toward people who have work-based insurance coverage — as long as that coverage is continuous for at least 12 months with lapses no longer than 63 days. One expert we consulted pointed out that this window could be especially problematic now, during a time of "enormous economic dislocation."

Additionally, the ACA rewrote the HIPAA provisions regarding preexisting conditions — bringing into question what might become of them, too.

We rate Azar's claim Mostly False.

Julie Rovner: jrovner@kff.org, @jrovner

Across the country, the recession has cut state revenues at the same time the pandemic has increased costs, forcing lawmakers into painful decisions about how to balance their budgets.

This article was first published on Friday, July 10, 2020 in Kaiser Health News.

By Markian Hawryluk

As a teenager, Paulina Castle struggled for years with suicidal thoughts. When her mental health was at its most fragile, she would isolate herself, spending days in her room alone.

“That’s the exact thing that makes you feel significantly worse,” the 26-year-old Denver woman said. “It creates a cycle where you’re constantly getting dug into a deeper hole.”

Part of her recovery involved forcing herself to leave her room to socialize or to exercise outside. But the COVID-19 pandemic has made all of that much harder. Instead of interacting with people on the street in her job as a political canvasser, she is working at home on the phone. And with social distancing rules in place, she has fewer opportunities to meet with friends.

“Since the virus started,” she said, “it’s been a lot easier to fall back into that cycle.”

Between the challenges of the pandemic, the social unrest and the economic crisis, mental health providers are warning that the need for behavioral health services is growing. Yet faced with budgetary shortfalls, Colorado is cutting spending on a number of mental health and substance use treatment programs.

Across the country, the recession has cut state revenues at the same time the pandemic has increased costs, forcing lawmakers into painful decisions about how to balance their budgets. State legislatures have been forced to consider health care cuts and delay new health programs even in the midst of a health care crisis. But many lawmakers and health experts are concerned the cuts needed to balance state budgets now could exacerbate the pandemic and the recession down the line.

“Health care cuts tend to be on the table, and of course, it’s counterproductive,” said Edwin Park, a health policy professor at Georgetown University. When there’s a recession, people lose their jobs and health insurance, he noted, the very moment when people need those health programs the most.

‘Everything Has To Be On The Table’

In Colorado, for example, lawmakers had to fill a $3.3 billion hole in the budget for fiscal year 2020, which started July 1. That included cuts to a handful of mental health programs, with small overall savings but potentially significant impact on those who relied on them.

They cut $1 million from a program designed to keep people with mental illness out of the hospital and another million from mental health services for juvenile and adult offenders. Lawmakers reduced funding for substance abuse treatment in county jails by $735,000 and eliminated $5 million earmarked for addiction treatment programs in underserved communities. And that’s all on top of a 1% cut to Medicaid community providers who offer health care to the state’s poorest residents.

Some of those cuts were offset by $15.2 million in federal CARES Act funding allocated to behavioral health care programs. But some programs were completely defunded. Cuts were targeted primarily at programs that hadn’t started yet or hadn’t been fully implemented. The rationale: Those cuts wouldn’t have as deep an impact.

Doyle Forrestal, CEO of the Colorado Behavioral Healthcare Council, which represents 23 behavioral health care providers, worries that resources won’t be there for an emerging wave of people who have developed mental health or addiction issues during the pandemic.

“People who are isolated at home are drinking a lot more, maybe having other problems — isolation, economic despair,” she said. “There’s going to be a whole new influx once all of this takes hold.”

State legislators said they tried to avoid cutting programs that would hamper the response to the pandemic or the economic recovery.

“There was a desire on both sides to do everything we could to protect health care spending in Colorado,” said Democratic Rep. Dylan Roberts. “But when you’re looking at across-the-board cuts, everything has to be on the table.”

Every state is facing a similar conundrum. With tax filing deadlines pushed back to July 15, states are unsure how much income tax revenue they will collect.

So in addition to cutting back where possible, states are raiding discretionary funds — Colorado repurposed money from the tobacco settlement and marijuana taxes — to shore up their budgets. States are also tapping rainy day funds, which, according to the National Association of State Budget Officers, grew to record levels after the 2008 recession.

New Policies Delayed

Overall, at least 43 states have made some changes to facilitate access to Medicaid or the Children’s Health Insurance Program as many people have lost their job-based health insurance in the COVID crisis. And in late June, voters in Oklahoma approved expanding Medicaid to more residents. But since the start of the pandemic, states including Kansas and California have put off plans to expand eligibility for Medicaid, which provides health care to low-income people.

“These are symptoms of states that can’t deficit-spend, despite this great need for more coverage,” said Sara Collins, vice president for health care coverage and access at the Commonwealth Fund, an independent health policy research foundation based in New York. “If they spend more in one area, that means cuts in another.”

Colorado has had an aggressive health agenda in recent years but had to defer plans for a public health insurance option that could have provided a more affordable plan for people buying insurance on their own.

The legislature killed a proposal to create an annual mental health checkup. The measure would have cost the state only $13,000, but Democratic Gov. Jared Polis signaled he wouldn’t sign any bills that included new mandates for insurance companies.

Democratic Rep. Dafna Michaelson Jenet, who sponsored the checkup measure, was disappointed.

“Not every one of us is going to catch COVID, but every single one of us will have a mental health impact,” she said.

Long-Term Implications

Once the economic crisis eases, Roberts said, lawmakers will look to restore funding to some of the programs they cut.

But cuts are often easier to make than to restore — as illustrated by cutbacks made during the 2008 recession, according to Georgetown’s Park.

“Many cuts were never fully restored, even though we were in one of the longer economic expansion periods in our country’s history,” Park said.

He also worries many of the smaller primary care and behavioral health providers, who saw fewer patients come through their doors because of stay-at-home orders during the pandemic, might not survive.

“That means less access to care, including routine care like vaccinations,” he said. “If kids aren’t vaccinated, they may be more vulnerable to flu and measles, making them more vulnerable to COVID-19. That makes it more difficult for a stressed health care system to try to deal with a potential second wave of infections.”

The longer-term mental health toll may be harder to catalog.

Castle, for one, has focused on establishing routines to help her manage her mental health during the pandemic. Every Wednesday night, she plays games online with her friends. And every Friday night, she and her boyfriend build a fire in the backyard.

“If I know people are expecting me to be somewhere at 6 o’clock, that obligation encourages me to go out,” she explained. “There are days it’s a struggle. I have to focus on baby steps.”

Still, Castle worries about others who may be struggling during the pandemic. She has signed on to work with the Colorado chapter of Young Invincibles, which lobbies for health care, higher education and workforce policies to help young adults. Even as states and the federal government have found the money to help hospitals and doctors treat the physical effects of the COVID pandemic, she doesn’t see the same commitment to treating its mental health toll.

“We need to start treating mental health the same as we do physical health,” she said. This is an issue we need to stop keeping in the dark.”

If you or someone you know is thinking about suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255, or use the online Lifeline Chat, both available 24 hours a day, seven days a week.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

"If Donald Trump has his way, complications from COVID-19 could become a new preexisting condition," says former Vice President Joe Biden during a campaign speech in Lancaster, Pennsylvania.

This article was first published on Thursday, July 9, 2020 in Kaiser Health News.

By Julie Appleby

The same day the Trump administration reaffirmed its support of a lawsuit that would invalidate all of the Affordable Care Act, Joe Biden sharply warned that the suit endangers millions of Americans.

The presumptive Democratic presidential nominee said the law is even more important now, more than a decade after it was enacted, as the COVID-19 epidemic sweeps the U.S. The virus has killed more than 130,000, and Biden noted that some who survive may have long-lasting health problems.

His speech in the battleground state of Pennsylvania focused on a legal challenge headed to the Supreme Court and the fallout if the court upholds a 2018 U.S. District Court decision that struck down the entire ACA, including preexisting condition protections that bar insurers from rejecting people with medical problems or charging them more.

“And perhaps most cruelly of all, if Donald Trump has his way, complications from COVID-19 could become a new preexisting condition,” Biden said.

The Trump administration has supported the challenge. A decision from the Supreme Court is expected next year, after the November presidential election.

But would a decision against the health law affect COVID-19 patients in the way Biden described?

We decided to check because it’s likely to come up a lot in the presidential electioneering. We reached out to the Biden campaign to find out the basis for his statement. A campaign spokesperson responded by reiterating the points made by the former vice president in his speech and sharing various news stories about COVID-19 and the preexisting condition coverage issue.

Several law and health policy experts noted that Biden is on fairly firm ground, though the issue — like many others in health care — is complicated.

First, A Little History

Before the ACA went into effect in 2014, insurers on the private market could reject applicants for coverage if they had any number of medical conditions, such as cancer, depression, heart disease — even high blood pressure, acne or plantar fasciitis. Consumers had to fill out forms listing their medical conditions when applying for coverage. An estimated 54 million Americans have a preexisting condition that could have led to a denial under pre-ACA rules, researchers estimate.

Also, at the time, some consumers had coverage cancelled retroactively once they fell ill with a serious or costly disease, as insurers would then comb through years of medical records looking for anything the consumer had failed to report as preexisting, even if it seemed to have little or nothing to do with the patient’s current medical concern.

Those rejections and cancellations mainly affected people who bought their own coverage, not those who got insurance through their jobs.

Job-based coverage, which is the main way most insured people get their plans, had some protections prior to the passage of the ACA. For example, the federal Health Insurance Portability and Accountability Act of 1996 said people who held health insurance continuously for at least a year could not face preexisting condition limits when they enrolled in a new employer plan, as long as they didn’t go uninsured for more than 63 days.

Those who didn’t meet that yearlong coverage requirement or went uninsured between jobs could find their medical conditions excluded for up to a year in a new group plan.

Before the ACA, insurers broadly defined preexisting conditions. Many included any condition for which a patient had received treatment, or even undiagnosed conditions for which a reasonable person should have sought treatment.

The ACA changed that. Among other things, it barred insurers from rejecting applicants based on their health, excluding coverage of preexisting medical conditions and charging sick people more than healthier ones. It also ended annual or lifetime dollar limits on coverage and said employers that offer insurance can’t make new workers wait more than 90 days for coverage to kick in.

Could COVID-19 Become A Preexisting Condition?

Biden’s comment raises the question of whether COVID-19 would be considered a preexisting condition in a future without the sweeping health law on the books.

Because the virus is so new, there’s no definitive answer on its long-term health effects.

But media reports note hospitals and physician groups are finding evidence that some recovered COVID patients suffer from lung damage, blood clots, neurological conditions, strokes or fatigue.

Researchers are now starting to follow patients to track long-term effects.

Given insurers’ history, it’s certainly reasonable to assume they would put what are now cropping up as potential COVID complications in the preexisting-condition category, said Sabrina Corlette, who studies the individual insurance market as co-director of the Center on Health Insurance Reforms at Georgetown University.

“There is a real concern that if those preexisting condition protections are overruled or taken down by the Supreme Court, people who have COVID-19 could be medically underwritten, charged more or be denied a policy,” said Corlette.

That is possible, said Joe Antos, resident scholar in health policy at the conservative American Enterprise Institute. But many of the people most likely to suffer complications from the coronavirus likely already had conditions like diabetes, asthma or heart disease that would already have put them in danger of being rejected for coverage under pre-ACA business practices, he added.

In other words, COVID-19 could simply find a place on a long list of other conditions that could disqualify consumers from obtaining insurance.

And even if the high court tossed out the ACA, insurers might choose to keep offering coverage to people with health problems, say some analysts, including Antos.

But this take triggers skepticism.

“Insurance companies have an obligation to shareholders, and that obligation is to maximize profits,” Corlette said. “They don’t do that by covering a lot of sick people when competitors are not doing it.”

The Biggest Unknown

Just how would Congress and the president react if the ACA is struck down?

Under a Biden presidency, coupled with Democrats holding the House and possibly winning the Senate, the ACA would definitely be replaced, the experts all agreed.

Under a second-term Trump administration, Republicans would face a dilemma because — even though the party has called for the law’s repeal since its enactment –— they have been unable to agree on how to replace it. Yet polls have consistently shown that parts of the law, especially the preexisting condition protections, are very popular with a wide swath of voters.

“They don’t want to come across as coming up hard against people who have health conditions,” said Antos.

Private practice attorney Christopher Condeluci, who served as tax and benefit counsel to the Senate Finance Committee when the ACA was drafted, agreed. He thinks Congress or the president would act to save the preexisting condition protections at least.

But how to do so is problematic. That provision is intricately tied with many other parts of the ACA, those aimed at getting as many healthy people to enroll as possible in order to spread costs out among the many, rather than the few.

The ACA did that partly by requiring most Americans to carry insurance coverage — the provision at the heart of the Texas lawsuit seeking to overturn the legislation. Restoring that requirement might be tricky, so the path forward for a split Congress or a second-term Trump presidency to come up with a solution quickly — or at all — if the Supreme Court tosses the entire law is a difficult one.

Our Ruling

Biden said that if Trump had his way, COVID complications could become a preexisting condition. He said this while discussing what might happen if the ACA is overturned by the Supreme Court. Though the statement can’t be definitively proven, there’s a lot of evidence backing it up.

First, some patients are showing at least short-term aftereffects of COVID-19, some of which could be costly. Some may prove long-term.

Second, insurers dislike costly medical conditions. Their business model is designed to have enough healthy enrollees to offset those with costly conditions. Before the ACA, they did that by rejecting people with medical conditions, charging them more or excluding coverage for those conditions. Some also temporarily delayed coverage for specific conditions in group plans offered by employers. Without the ACA, no federal law would prevent them from returning to these practices when selling plans on the individual market.

We rate Biden’s statement Mostly True.