During his 2020 State of the Union address, President Donald Trump described his “ironclad pledge” to protect patients with pre-existing conditions. A few days later, President Trump released his 2021 budget proposal, which is the foundational document for the administration’s health care policy goals. But instead of any policy to protect the millions of Americans with pre-existing conditions should the lawsuit to overturn the Affordable Care Act be successful, the President’s only concrete plan appears to be massive cuts in spending on health care programs.

The President’s budget proposal would cut federal funding by $844 billion between 2021-2030 as part of his “health reform vision” (undefined). While the proposal asserts that “The President’s healthcare reforms will protect the most vulnerable, especially those with pre-existing conditions,” most of the $844 billion in cuts would come from the Medicaid program, which serves our nation’s most vulnerable citizens, including 45 million children and 7 million elderly with long-term care needs.

Although his budget document is silent on how people with pre-existing conditions would be protected, the administration’s actions, rather than its words, speak loudly:

• Joining a group of Republican state attorneys general and governors who brought a lawsuit against the ACA, arguing that the entire law should be overturned;
• Asking Congress to repeal the Affordable Care Act (ACA) without a viable replacement plan for ensuring access to comprehensive and affordable health care for people with pre-existing conditions;
• Expanding the availability and promoting the sale of non-ACA-compliant products, which discriminate against people with pre-existing conditions by charging higher premiums, refusing to cover treatment, or denying coverage entirely;
• Rolling back the ACA’s individual mandate and cutting off federal funding for cost-sharing reductions, leading to market uncertainty and higher premiums in the individual market; and
• Dramatically reducing the federal budget for advertising and consumer assistance during the ACA’s annual Open Enrollment Period, cutting resources that help people obtain high quality, comprehensive coverage.

All the while, the promised “phenomenal” health care plan has yet to materialize.

Currently, the lawsuit that could overturn the ACA in its entirety awaits further action by the Supreme Court of the United States. If the plaintiff states and the Department of Justice’s stance prevails, the Trump administration’s “to-be-determined” plan would have serious ramifications, such as:

• An estimated 20 million people could lose their health insurance;
• People with pre-existing conditions (which includes a whole host of health issues) could be charged much higher premiums, or be denied coverage altogether; and
• Insurers could exclude coverage of treatment for health conditions they determine to be pre-existing, or coverage of treatment deemed too expensive, such as maternity care or prescription drugs. Even people with employer coverage could be subject to waiting periods of up to a year for coverage of treatment for their pre-existing conditions.

President Trump says he will protect people with pre-existing conditions. But as his administration continues to support a lawsuit to overturn the ACA, tout cheap alternatives that discriminate against sick people and leave others critically underinsured, and pave the way for states to sidestep the ACA’s consumer protections, his “ironclad pledge” rings hollow. And for the millions of Americans relying on the ACA’s legitimate protections for pre-existing conditions, these empty promises could have life-or-death consequences.