**VP Debate Ignites Controversy on Health Coverage for Pre-Existing Conditions**

In Tuesday night’s vice presidential debate, Republican nominee Sen. JD Vance of Ohio pledged to safeguard health insurance for individuals with pre-existing conditions while advocating for their placement in high-risk pools, a proposal that divided opinions. Policy analysts pointed out the inconsistency of these two statements, recalling the era before the Affordable Care Act (ACA) mandated coverage for pre-existing conditions.

Arthur Caplan, the head of medical ethics at NYU Langone Medical Center, expressed skepticism about Vance's suggestion. “Anything that separates out pre-existing conditions is doomed to utter failure,” he remarked, emphasizing the historical shortcomings of such strategies.

Before the ACA's enactment in 2010, many states used high-risk pools to insure people with chronic illnesses, according to Cynthia Cox, vice president and director of the ACA program at KFF, a research organization specializing in health policy. These pools also applied to those in a "gray zone," where minor health issues could lead to exorbitant premiums. Cox noted that the sickest 5% of the population, typically those with chronic illnesses, account for more than half of all healthcare expenses—leading insurers to label them "uninsurable" and deny coverage.

High-risk pools were intended to provide a safety net for these individuals, grouping them together to entice insurers by reducing some financial risk through state funding, mandates, and federal grants. However, these pools were severely underfunded, leading to higher premiums and limited coverage for the patients they were supposed to protect. Cox highlighted that entering a high-risk pool often came with exclusions on coverage for up to a year.

The ACA sought to eliminate high-risk pools by introducing a single-risk pool where healthier individuals subsidize the costs for those with chronic conditions. John A. Graves, a professor of health policy and medicine at Vanderbilt University, described this as a "social contract" where everyone contributes equally, ensuring support when individuals eventually face higher healthcare costs.

Democratic nominee Minnesota Gov. Tim Walz shared a similar stance during the debate, emphasizing the need for a broad risk pool to maintain the functionality of insurance. Graves conceded that high-risk pools could work again but only with substantial government subsidies to keep premiums affordable. Without such subsidies, premiums for the sick would invariably rise.

Cox and Caplan both cast doubt on the effectiveness of returning to a high-risk pool model, noting the significant federal funding it would require without a clear advantage. “You have to share the risk broadly, in a large group, to make it affordable,” Caplan said. “We had isolated pre-existing pools for the past 25 years, and they don't work.”