In the waning days of the presidential election, President Donald Trump’s vows to dismantle the Obama-era Affordable Care Act have come with repeated promises to “guarantee” protections for people with pre-existing medical conditions like cancer and diabetes.

Democratic challenger Joe Biden has promised to build on the current health care law, including its protections for pre-existing conditions. The Republicans, he has argued, don’t actually have a viable replacement plan for people suffering from chronic maladies.

For nearly 800,000 Minnesotans who have one or more of the pre-existing conditions that insurers most commonly used to deny or limit coverage, the debate could be one of the most personally consequential of the election.

Almost as soon as a winner is declared, the new 6-3 conservative majority on the U.S. Supreme Court is poised to hear another legal challenge to the Affordable Care Act. If the law is struck down, its supporters say, protections for people with pre-existing conditions would fall into a void.

Candidates in both parties promise to maintain those protections — one of the most popular features of the 2010 health care law. But Trump and Republicans in Congress have so far failed to enact a law that specifically codifies protections for people with pre-existing protections.

Minnesota’s three Republican congressmen say that they support the protections for pre-existing conditions while opposing the Affordable Care Act’s coverage mandate, which still exists but has no teeth because the penalty was eliminated by Congress in 2017.

In September, Trump signed an executive order declaring that it was the policy of the United States to protect pre-existing conditions, an assertion he has made many times that has gained traction within his party. According to a survey by the California-based Kaiser Family Foundation, 83% of self-identified Republicans believe he has a plan to do that.

But a policy statement does not have the force of law.

“It is not just saying that you are going to do it. You actually have to pass a law,” said Lynn Blewett, a professor at the University of Minnesota School of Public Health.

In 2017, the Republicans in the U.S. House passed a partial repeal of the law known as Obamacare that included protections for pre-existing conditions, but it also allowed states to opt out of the requirement. A Senate version failed by one vote, effectively ending the GOP’s efforts to repeal the law through legislation.

Obamacare does more than mandate that insurers cover those with current or past medical conditions, including cancer, heart disease, diabetes and kidney disease.

It also has provisions that help make those protections possible, including premium subsidies, a ban on annual and lifetime benefit caps and a set of essential benefits that all health plans must provide.

“All of these are the protections that ensure that people with pre-existing conditions have a robust set of benefits,” said Maanasa Kona of the Center on Health Insurance Reforms at Georgetown University’s Health Policy Institute.

“Removing even one piece tends to make it all fall apart,” she said.

Wiping the Affordable Care Act off the books would have mixed results in Minnesota, which has some protections for those with underlying health conditions written into state law.

But Minnesota law does not require “guaranteed issue,” meaning that a health insurer can refuse to cover someone based on their health status.

At least 23% of Minnesotans, or 790,000, have one or more of the pre-existing conditions that insurers most commonly used to deny or limit coverage, according to an analysis by the Kaiser Family Foundation.

The 160,000 Minnesotans who get health insurance in the individual market are most vulnerable, including 60,000 who receive premium tax credits that make coverage more affordable.

The elimination of the current health care law would also mean the end of the Medicaid expansion, which covers 200,000 people, and MinnesotaCare, which has 90,000 enrollees. Both programs receive federal subsidies under the Affordable Care Act.

Minnesota Democrats have lined up behind keeping the law in place, though some have put forward tweaks: U.S. Rep. Angie Craig, who made health care central to her successful 2018 campaign against Republican incumbent Jason Lewis, sponsored a federal “reinsurance” bill, modeled after a Minnesota program, that would have allocated $10 billion annually to insurance companies to offset premium hikes driven by coverage for high-cost patients.

Minnesota’s three Republican congressmen are all up for re-election next week. Only one of them — Rep. Tom Emmer — has been in Congress long enough to have voted for the many health law repeal efforts put forward by Republicans between 2011-2017.

In response to questions from the Star Tribune, Emmer said he supports “expanding access to health insurance coverage for those who want it without imposing new federal taxes or mandates.” He provided no specifics beyond giving states more responsibility to maintain protections for individuals with pre-existing conditions.

“The federal government should focus on creating a regulatory structure that encourages states to develop their own systems of coverage,” Emmer said.

Rep. Jim Hagedorn, first elected in 2018 and now in a tight re-election race against Democrat Dan Feehan in southern Minnesota, said the health law “imposed many arbitrary mandates and taxes that hurt the American people.” He is opposed to the individual mandate and said that “Minnesota didn’t need Obamacare,” citing the state’s high health insurance coverage rate.

Hagedorn said he backs federal legislation to encourage the creation of association plans in hopes of promoting competition that would push down the costs of premiums and deductibles. He also favors price transparency on medical procedures to encourage consumer shopping for care, high-risk pools backed by federal and state governments for patients with pre-existing conditions, use of pretax dollars for Americans to pay for health insurance, care and prescription drugs, and an array of prescription drug pricing reforms.

Until the federal health care law was implemented in 2013, Minnesota had one of the oldest high-risk pools, which cover those who can’t get insurance elsewhere because of pre-existing conditions.

Funded by assessments levied against health insurers, as well as member premiums that were up to 125% of the market rate, the pool required several bailouts. If pools were reintroduced, they would likely need taxpayer support to survive.

“It served a small number of people very well,” said Blewett. “But it needed to be those people who had income and could afford the premium.” When it was shut down, Minnesota’s pool had 26,000 enrollees.

Rep. Pete Stauber, elected in 2018, has taken the most pro-Affordable Care Act stance of any prominent Minnesota Republican. In 2019, he was one of a small handful of House Republicans who joined Democrats in supporting a resolution backing the health law.

Still, Stauber said he does not support the individual mandate. “Rather than fining families for being unable to afford insurance, I am working with Republicans and Democrats to reduce the cost of health insurance,” he said.

Stauber said he has supported legislation that would “ensure coverage for pre-existing conditions remains mandatory regardless of what may happen in the courts.”

The details, however, remain to be seen.