The Patient Protection and Affordable Care Act (PPACA) created a temporary insurance program for people with pre-existing conditions: the Pre-Existing Condition Insurance Plan (PCIP), also known as the high-risk insurance pool. This program was designed to last only until 2014; under the healthcare reform law, most insurers will not be able to discriminate against people with pre-existing conditions beginning in that year.

The healthcare law allocated $5 billion to create the PCIP, which helps pay states and the District of Columbia to run the program. However, Republicans have criticized this part of the law as being overfunded, as participation has been far below what Democrats projected.

For example, the Centers for Medicare and Medicaid Services estimated that 375,000 people would be signed up for the coverage by 2010, but only about 12,000 signed up by then. As of August 2012, just over 86,000 people were enrolled.

In 2011, House Republicans charged the Obama administration with trying to "save face" by increasing advertising and other outreach efforts to get people to enroll. Republicans openly questioned where the administration was getting the money to pay for the outreach efforts.

Expanding high-risk insurance coverage would primarily mean an expansion to the more than 4 million residents of Puerto Rico, which has a higher population than all other territories combined.