“Yes, they are expecting to still be in there, preexisting conditions and older children, young adults up to the age of 26. Actually, preexisting conditions and 26-year-olds were two Republican provisions which made it into the [Obamacare] bill.”
— Rep. Marsha Blackburn (R-Tenn.), remarks at a town hall in Fairview, Tenn., Feb. 21, 2017

Among the most popular parts of the Affordable Care Act, passed in 2010 with zero votes from Republican lawmakers, are provisions that prohibit insurance companies from denying coverage based on a preexisting condition and allowing adult children up to the age of 26 to be carried on their parents’ health plan. As Republicans craft a replacement for Obamacare, many have suggested that these ideas will be carried forward.

Yet we were surprised when we saw that, in response to a question about whether these provisions would be in the replacement, Rep. Marsha Blackburn told people in her district that these were actually “two Republican provisions which made it into the [Obamacare] bill.”

Could this be possible? Blackburn’s staff did not respond to repeated inquiries over several days for an explanation — generally a sign that the boss has messed up.

The Facts

The ACA was crafted through many months of committee hearings and debates in 2009, in both the House and the Senate, and untangling who was responsible for what is a difficult chore. But we checked with a number of congressional aides and other experts who were involved in the process at the time and could find few, if any, Republican fingerprints on these two provisions in the legislative process.

Preexisting conditions

Barring insurance companies from denying coverage based on preexisting medical conditions had long been a holy grail of health-care reform. Chris Jennings, a health-care consultant who worked for both presidents Bill Clinton and Barack Obama, said the question of how to achieve this dates back to the Health Insurance Portability and Accountability Act of 1996, sponsored by Sen. Edward M. Kennedy (D-Mass.) and Sen. Nancy Kassebaum (R-Kan.). That law required insurance companies to nullify preexisting-condition exclusions for people who had continuous coverage and were joining a group health plan at work. But it did not offer any protection if someone moved from a plan in the individual market to another plan, or from an employer plan to the individual market.

Jennings said the Clinton administration and Congress were able to “enhance protections (in a bipartisan fashion) for people going from insurance market to insurance market but we could not eliminate the underwriting practice altogether because we could not require a health plan to insure a ‘house on fire’ patient unless we had near or close to universal coverage.” Universal or near-universal coverage was the key, because then the pool of people in the insurance market would be broad enough that insurance companies could cover sicker people without increasing premiums.

When individual states tried to insist on guaranteed coverage, premiums skyrocketed. Many states also established high-risk pools to help cover people with preexisting conditions, but they ran up losses, excluded coverage for preexisting conditions, often for six to 12 months, and imposed lifetime limits on coverage.

In 2006, Massachusetts Gov. Mitt Romney (R) enacted a health-care plan that included an individual mandate to buy insurance, thereby expanding the pool of people buying insurance. The Massachusetts law required coverage of preexisting conditions but even it did limit coverage of some conditions to six months.

“Policymakers of both parties knew what would be necessary to get the job done — this is best exemplified subsequently by the Romney Massachusetts policy (that had the subsidies/mandate pillars) in order to get the preexisting condition exclusions eliminated,” Jennings said.

The individual-mandate approach is what emerged in the bills crafted by Democrats in the House and the Senate. In the House, the Affordable Care Act for America Act (H.R. 3962) was introduced on Oct. 29, 2009, and then passed by the House on Nov. 7, 2009. In the Senate, Kennedy was a fierce proponent of ending the preexisting coverage ban. The final version of the ACA enacted the ban on barring coverage of preexisting conditions, aided by the creation of a temporary, national high-risk pool that served as a bridge from 2010 to 2014, when the Obamacare markets would be operational.

But the Republican alternative did not offer coverage for preexisting conditions. On Nov. 6, 2009, in an interview on C-SPAN, Blackburn was specifically asked about that criticism — and she touted instead an expansion of high-risk pools. “There is a way to do that, and address that, and bring people into those high-risk pools,” she said. The Republican alternative to the House bill would have allocated $24 billion over 10 years to fund high-risk pools for people with chronic illnesses, but a Congressional Budget Office analysis of the proposal found it would have had a minimal impact on reducing the number of uninsured Americans.

Under-26 provision

Before the ACA, a number of states had a similar policy, but it was not as broad or consistently applied. So Democratic policymakers sought ways to add young adults to the insured rolls, as many lost coverage at the age of 19, when they graduated from high school or when they graduated from college.

President Obama pushed for the idea early on, listing it as a key element in his plan in speeches. Sen. Chris Van Hollen (D-Md.), at the time a member of the House, also led a campaign starting in October 2009, with other House Democrats, to include it in the emerging House bill.

Chiquita Brooks-LaSure, a staff member at the time on the House Ways and Means Committee, recalled that an additional motivation for adding the provision was to demonstrate benefits from the law before the exchanges went into operation later. The under-26 provision went into effect on Sept. 23, 2010.

“There was certainly no Republican pushing either provision, but Senators [Chuck] Grassley [R-Iowa] and [Olympia] Snowe [R-Maine], who were the only ones working with us in the Senate, accepted them as must-do in the end,” recalled a former Senate aide.

Update: Blackburn’s staff suggested that Blackburn co-sponsored legislation in November, 2009, which included these provisions. But the bill never came to a vote — and records show Blackburn signed on as a co-sponsor in June, 2010, after the Affordable Care Act was signed into law. There were a handful of other GOP bills with these sorts of provisions, which also did not go far, as well as some rhetorical support by some Republicans.

The Pinocchio Test

There is no evidence that either of these popular elements of the ACA “were Republican provisions,” as Blackburn claims. In fact, Blackburn is on record as promoting the concept of federally funded “high-risk pools” even on the eve of the House vote for the Democratic bill that included a robust provision to bar insurance companies from refusing to cover preexisting conditions. Similarly, the Obama White House and House Democrats were the prime movers of the under-26 provision.

Blackburn earns Four Pinocchios.

Four Pinocchios

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"Preexisting conditions and 26-year-olds were two Republican provisions which made it into the [Obamacare] bill.”
in a town hall in Fairview, Tenn.
Tuesday, February 21, 2017