In their newly released “Pledge to America,” House Republicans call for repealing the Affordable Care Act. They advocate replacing it with legislation incorporating a number of components long advocated by the GOP, including reforming the medical liability system, allowing the purchase of health insurance across state lines, and expanding health savings accounts.

One of these components, medical liability reform, is a major focus of the September issue of Health Affairs, and was discussed by several panelists at a National Press Club release event for the volume. In one article in the issue, Harvard’s Michelle Mello and coauthors find that the annual costs of the medical liability system — including “defensive medicine,” i.e., tests and procedures ordered by medical providers to avoid malpractice litigation – amount to $55.6 billion in 2008 dollars, or 2.4 percent of total health care spending. This “represents a small fraction of total health care spending, yet in absolute dollars, the amount is not trivial,” write Mello and coauthors Amitabh Chandra, Atul Gawande, and David Studdert.

… And Pre-Existing Condition Coverage

Under the heading “Ensure Access For Patients With Pre-Existing Conditions,” House Republicans propose to expand high-risk pools and reinsurance programs, and they say they would reduce the costs of coverage. The effectiveness of these proposals would obviously depend heavily on structural details and funding levels. (In the June issue of Health Affairs, Deborah Chollet discusses some of the history of state high-risk pools and the challenges they have encountered.)

The Pledge also states: “We will make it illegal for an insurance company to deny coverage to someone with prior coverage on the basis of a pre-existing condition, eliminate annual and lifetime spending caps, and prevent insurers from dropping your coverage just because you get sick.” (emphasis added)  As has been pointed out elsewhere, this would not broadly prohibit insurers from discriminating against people with pre-existing conditions, as the Affordable Care Act does. The language would allow insurers to refuse to cover uninsured people with pre-existing conditions. It would also allow insurers to charge higher premiums or offer only limited coverage to people with pre-existing conditions.

Republicans have vehemently opposed the individual mandate – the requirement that those who can afford it purchase coverage – contained in the Affordable Care Act. (The June issue of Health Affairs features a pro and con discussion of the individual mandate and the constitutional challenges to it brought by several states.) Without such a mandate, many analysts warn, prohibiting insurers from discriminating against all Americans with pre-existing conditions would enable people to wait until they got sick to purchase coverage and thus lead to higher premiums.