In the debate over the future of the Affordable Care Act (ACA), proposals have emerged that would repeal or weaken rules prohibiting health insurance discrimination based on health status, instead offering high-risk pools as a source of coverage for people who would be uninsurable due to pre-existing conditions.

In Congress, HR 2653 was introduced by members of the House Republican Study Committee to repeal the ACA and replace it with other changes, including state high-risk pools.  This bill would authorize $50 million for seed grants to help states establish high-risk pools, and $2.5 billion annually for 10 years to help states fund high-risk pools.  Recently, House Republicans released their proposal to replace the ACA, entitled A Better Way.  This plan would significantly modify ACA insurance market rules to provide a one-time open enrollment opportunity; thereafter, only individuals who maintain continuous coverage would be guaranteed access to insurance without regard to their health status.  This plan also would provide $25 billion over 10 years in state grants to help fund high-risk pools.  Pools would be required to cap premiums (at unspecified levels) and would be prohibited from imposing waiting lists.

For more than 35 years, many states operated high-risk pool programs to offer non-group health coverage to uninsurable residents.  The federal government also operated a temporary high-risk pool program established under the ACA to provide coverage to people with pre-existing conditions in advance of when broader insurance market changes took effect in 2014.  This issue brief reviews the history of these programs to provide context for some of the potential benefits and challenges of a high-risk pool.