Donald Trump sees letting health insurers sell coverage across state lines as a major component of an effort to replace the Affordable Care Act.

The Republican presidential nominee talked about interstate health coverage sales Sunday in St. Louis, during the second 2016 presidential debate, which was broadcast over the air and on cable and streamed live on the Web by many organizations.

The moderators presented a question from Ken Karpowitz, an audience member who was described as an undecided voter. Karpowitz asked what Trump and Hillary Clinton, the Democratic contender, would do to bring the cost of health coverage down and make the coverage better.

Related: Trump, Bill Clinton clash over ‘craziest’ ACA thing

“We have to get rid of the artificial lines around the states, where we stop insurance companies from coming in and competing,” Trump said.

The current state-based regulatory system “gives the insurance companies, essentially, monopolies,” Trump said. “We want competition.”

The ACA now includes a provision that prohibits sellers of new individual major medical coverage from considering personal health factors other than an applicant’s age and location when deciding whether to accept an applicant, and from considering personal health factors other than age, location and tobacco use when pricing coverage.

Clinton argued that eliminating the ACA could let health insurers bring back medical underwriting. “We turn it back to the insurance companies, the way it used to be,” Clinton said.

Anderson Cooper, one of the moderators, asked Trump about Trump’s past statements that he wants to eliminate the ACA and also to make health coverage accessible to people with health problems.

Related: Pence attacks ACA in vice presidential debate with Kaine

“How do you force insurance companies to do that if you are not mandating that everyone has insurance?” Cooper asked.

Trump argued that using interstate health insurance sales to increase competition would make coverage accessible to people with health problems.

“You’re going to have plans that are so good, because we’re going to have so much competition, in the insurance industry, once we break out the lines and allow the competition to come in,” Trump said. “We’ll also be able to help people that can’t get, or don’t have, money, because we’re going to have people protected.”

Trump said the drafters of the ACA kept the existing state-based health insurance regulatory system, rather than allowing interstate sales, at the last minute.

The ACA itself includes a Multi-State Plan provision that has allowed health insurers to engage in some interstate health coverage sales. The U.S. Department of Health and Human Services and the U.S. Office of Personnel Management have implemented the program in a fashion that continues to give states a major role in regulating the Multi-State Plan programs.

Regulators have not given clear information about how many people have ACA Multi-State Plan coverage, or how many Multi-State Plan coverage options have been available in the past, are in effect now or will be available in 2017.

In the past, both Republicans and Democrats at the Kansas City, Missouri-based National Association of Insurance Commissioners, a group for state insurance regulators, have argued that allowing interstate health coverage sales would do little to lower health coverage costs and might encourage insurers to move to the states with the weakest regulations and weakest regulators.

Clinton, meanwhile, said little about how she would change the ACA provisions that affect the commercial health insurance market but said she sees room for changes. 

Hillary Clinton questioned whether the ACA ban on medical underwriting would survive ACA repeal. (Image: C-SPAN debate screen capture)

During the second 2016 presidential debate, Hillary Clinton questioned whether the ACA ban on medical underwriting would survive ACA repeal. (Image: C-SPAN debate screen capture)

Clinton calls for ‘additional help to small businesses’

Clinton said the Affordable Care Act looks the way it does because the ACA drafters were trying to build on the U.S. health finance system that was in place before the drafters started to work.

“If we were to start all over again, we might come up with a different system,” Clinton said. “But we have an employer-based system. That’s where the vast majority of people get their health care.”

The ACA exchange system was meant to help uninsured people who earn too much to qualify for Medicaid, and the ACA coverage expansion programs have helped 20 million uninsured people get health coverage, Clinton said.

Clinton also talked about the ACA provisions that have their roots in the old “patients’ rights” bills that were circulated starting in the 1990s and early 2000s.

Clinton cited the ban on lifetime benefits limits, the ban on charging women higher premiums, the provision that requires plans to let parents pay to keep children on their coverage up to age 26, and the provision that prevents insurers from rejecting applicants with health problems.

“I want very much to save what works and is good about the Affordable Care Act,” Clinton said. “Let’s fix what’s broken about it, but let’s not throw it away and give it back to the insurance companies. That’s not going to work.”

Clinton did seem to acknowledge some room for improvement.

“We’ve got to get costs down,” Clinton said. “We’ve got to provide some additional help to small businesses, so that they can afford to provide health insurance.” 

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