When it comes to Obamacare, one of the largest issues is its guarantee of coverage for people with pre-existing conditions. This piece of the law says that private insurance companies cannot deny somebody a plan simply because they already have a health condition such as diabetes, epilepsy, multiple sclerosis or spinal cord injury. The ACA also requires insurance companies to cover treatments related to a pre-existing condition, such as regular physical therapy or even surgery for a pressure sore. If this protection goes away, millions of people are likely to lose their insurance — and people with disabilities will be at the front of the line.

Pre-existing conditions and the problem with insurance

The pre-existing conditions guarantee is one of the cornerstones of Obamacare, and the need for the often-criticized “insurance mandate.” This is because of the way that health insurance — or any type of insurance — works.

• Insurance companies take monthly premiums from a group of people

• This builds up a large fund of money

• When one person gets sick, money in the fund will pay for their medical expenses

• This ensures that somebody will get medical costs covered, if they pay monthly premiums

• Insurers balance premiums and expenses to break even, plus get some profit.

There’s a tricky problem with this, though. Insurance companies like to enroll people that have lower medical costs, because that will help the insurers keep their own expenses low. Also, people with few health issues are less likely to get insurance because they just don’t consider it worth the money. When insurance companies don’t get enough money from low-cost consumers, it makes it tough to cover those with higher medical expenses. So before the ACA, insurance companies outright refused to cover many people with pre-existing conditions — and if they did, they were free to charge higher premiums or limit the medical services they would provide. This left many people with pre-existing conditions in a bind: with little medical coverage, but high costs, their lives were in danger.

That’s where Obamacare comes in, and especially the individual mandate that gets so many headlines.

Under the ACA, the government struck a deal that would guarantee everybody gets covered and the insurance companies have decent balance sheets. The basics included:

• Insurance companies could not deny anybody healthcare based on a pre-existing condition. They also could not charge higher premiums because somebody has a condition.

• The government would create a system where everybody would purchase insurance and pay into the “fund” of premiums. The ACA does this by giving a tax penalty to people who don’t purchase insurance plans.

• Government agencies would also provide financial supports and other resources to help lower-income Americans afford insurance and buy into the market.

• This would help insurance companies balance their books by getting enough enrollees, and enough monthly premiums, to cover medical costs of people with pre-existing conditions. Then, everybody could get coverage.

Now, everybody would be covered. There were also other benefits, such as a limit on lifetime medical expenses and guarantees for disability-related medical expenses. These guarantees have made a huge difference for people with disabilities and other health conditions. People who have finally gotten insurance are able to get enough doctors’ visits and preventative care to stay healthy on a regular basis. Large medical treatments and procedures are covered, protecting lives and well-being. And people may no longer be forced to go into debt or go bankrupt just to get their healthcare needs met. It is a game changer and a gift to our community.

So, what’s going on now?

If the pre-existing condition rules have been a gift, what happens if they go away? Experts are saying that 20 or 30 million people will lose insurance if all of the ACA is repealed — and a huge chunk of this would be because of the pre-existing condition rules. Those that are able to keep insurance (or purchase it) will likely face higher costs and less disability-related coverage, as well. It will be back to the days of old, when we faced barriers galore.

Politicians in Washington realize that getting rid of the pre-existing condition rules is deeply unpopular, and the toughest part of an ACA repeal effort. Some have suggested other plans that claim to address pre-existing conditions, but they fall short. For example, a plan that was put forward in late January only let people with pre-existing conditions keep their coverage if they stayed on their current plan. If someone had a lapse in coverage, they could still be denied or charged higher costs when they tried to reapply. A similar, seven-page proposal was put forward by Rep. Greg Walden (R-OR), but it’s extremely broad and doesn’t guarantee anything for people who have a lapse in coverage.

If any of these replacement plans come into being, people with conditions that have a lapse in coverage will likely be stuck without insurance, again. Those that are covered may have to pay higher premiums and get less overall coverage and preventive care. Nothing provides the same protections that the current law has, or anything close. These issues — and more — will leave plenty of people out in the cold, well into the future.