With multiple reports that the Senate will present their version of a healthcare bill, dubbed the American Health Care Act (AHCA), in the coming days, experts, patients, and other groups that will be affected by the bill are anxiously waiting to see what is in it.
It’s been over a month since the U.S. House of Representatives passed their version of a healthcare bill designed to replace the Affordable Care Act (ACA) — also known as Obamacare — and the new version of the bill crafted in the Senate remains a mystery.
Nadereh Pourat, PhD, director at the Center of Health Policy Research at the University of California, Los Angeles (UCLA), said if the Senate version of the health bill remains similar to the house bill, it means a “repeal” of the ACA “plain and simple.”
“It’s about undoing Obamacare or ACA in one way or another,” Pourat told Healthline. “The first draft that came out of the House did that exactly. The Senate version from what you see appear in the media is not going to be very different in its purpose.”
A recent PatientsLikeMe poll taken in January surveyed 2,755 people living with chronic conditions in all 50 states. The poll revealed these people are increasingly in favor of modifying rather than replacing the Affordable Care Act (ACA), with 62 percent reporting the ACA needs minor modifications or is working well.
“Despite the partisan divide in Congress about what should be included in a healthcare plan, there is a singular voice in patients, who are agreed across party lines on the essential foundation for any plan,” Sally Okun, PatientsLikeMe’s vice president of advocacy, policy, and patient safety, said in a statement.
While the House version of the bill was estimated by the Congressional Budget Office to reduce the deficit by $119 billion over the coming decade, an estimated 23 million would be without healthcare in 2026 compared with estimates for the ACA.
However, little is known about the health bill currently being written in the Senate, so leading experts, patients, and other groups wait to see what will be released.
Tax credit changes
Christine Eibner, PhD, senior economist, and a professor at Pardee RAND Graduate School, said she is particularly focused on how tax credits will be changed and if they will differ from the House version of the bill.
Under the ACA, credits are given to individuals based mainly on family income, cost of insurance, and age. In the new health bill that passed the House, a flat tax would be given based mainly on age, and capped for people earning over a certain amount.
The bill passed by the House would provide tax credits between $2,000 up to $14,000 for individuals to help pay for insurance coverage if they don’t receive insurance from their employers.
“I want to see what happens with the tax credits in the individual market,” Eibner told Healthline. “It was widely pointed out that the tax credits were not as generous as the ACA” for certain groups.
Eibner said that she’s seen “a lot of discussion of will the Senate,” change how these credits are divvied up. However, no details about the bill have been released yet.
According to an analysis by the Kaiser Family Foundation, people who are older, have lower incomes, and live in areas where there are high insurance premiums are more likely to receive less in tax credits under the current AHCA bill passed by the house.
On the flip side, younger people with higher incomes will likely get more in tax credits than they do currently.
In a public letter addressed to the Senate, AARP Executive Vice President, Nancy LeaMond, cited concerns about the bill and its potential effect on older Americans. She highlighted changes in tax credits as one way seniors would likely have to pay more in premiums.
She also pointed out that under the House bill, insurance companies could charge far more for a plan covering an older American compared with a younger person. Under the ACA, insurance companies could only charge three times the amount (a 3-to-1 age rating), and under the new plan they could charge five times the amount.
“Taken together, the bill’s tax credit changes and a 5:1 age rating would result in skyrocketing cost increases for older Americans,” LeaMond wrote.
Eibner said she also wanted to see if the Senate will keep or get rid of a provision that could weaken protections for people with preexisting conditions.
In this provision states could apply for waivers that would exempt insurance companies from the “community rating.” This community rating provision implemented in the ACA is used to spread the cost of care across a larger pool. As a result of this requirement, people could not be charged a higher rate due to their health status.
Currently the ACA premiums are based on a person’s age, location, number of people covered on a health plan, and if the people covered use tobacco — not their health status.
If states apply for waivers to bypass the community rating, insurance companies could potentially charge far more if a person has an underlying health condition.
“That could lead to de facto differences” in costs for healthy and sick people, Eibner said. “If you're healthy person you’d get a lower premium.”
To qualify for a waiver, states would have to provide another way for these people to get care, most likely through a high-risk pool.
LeaMond pointed out that removing financial protections around preexisting conditions could mean a significant portion of older American’s could risk losing health coverage.
“The AHCA would remove preexisting condition protections and once again allow insurance companies to charge Americans more — we estimate up to $25,000 more — due to a preexisting condition,” LeaMond wrote. AARP estimates that about 25 million people, or 40 percent of people 50-64 years of age could be at risk for losing coverage due to this change.
All of these changes could severely impact how much older Americans pay in premiums.
According to analysis by the Congressional Budget Office, a 64-year-old making $26,500 per year could have their premiums go up from $1,700 a year to as much as $16,100, depending on if their state applies for a waiver.
If a 64-year-old is making over $68,200, their premiums may go down slightly from $15,300 to 13,600, or up slightly to $16,100 depending on if their state receives a waiver.
Essential health benefits
Another major change under the AHCA would be a provision that could weaken the essential health benefits requirement.
This provision would allow states to apply for a waiver so that insurance companies based in that state would not be required to cover all of the 10 essential health benefits that are currently mandated under Obamacare.
These essential health benefits were required to guarantee that people had robust coverage under all insurance plans and include benefits like prescriptions, mental health, and maternal care.
As a result of this provision, insurance plans may be far cheaper, but could leave people with serious gaps in their coverage if, for example, they don’t sign up for maternal health coverage and then become pregnant.
“A few million people will purchase something with their tax credit, but it wouldn't be good enough to be considered insurance,” Eibner said.
Changes to Medicaid
Under the AHCA, Medicaid would be turned from an open-ended per capita program — where the federal government gives states money based on need — to a block grant program where states would have a set amount of federal funds to pay for their programs.
Pourat pointed out that these changes could massively affect access to healthcare in this country.
These caps will “limit how much the state will get. In other words, it doesn't matter if there is widespread recession and incomes go down and people lose their jobs,” Pourat said. “The states, if they want to cover everyone, they'll have to do it with their own state funds,” after they get a set amount of Medicaid funds from the federal government.
AARP has issued concerns about the changes to Medicaid, reporting that the GOP-crafted health bill would lead to a 25 percent reduction, or a cut of $839 billion, over 2017-2026.
“We are concerned that these provisions would result in cuts to program eligibility, services, or both — endangering the health, safety, and care of millions of individuals who depend on the essential services provided through Medicaid,” LeaMond wrote in the letter addressed to senators.
Additionally, Medicaid expansion would be rolled back over time, starting in 2020. This expansion, which depended on states opting into the program, allowed people making no more than 133 percent of the federal poverty level to qualify for Medicaid. The federal government paid 90 percent of the costs for these patients.
These cuts could greatly impact older Americans, even those that qualify for Medicare. AARP estimates that among the 17.9 million people on Medicaid about 6.9 million are over age 65.
“Older adults and people with disabilities now account for approximately sixty percent of Medicaid spending, and cuts of this magnitude will result in loss of benefits and services for this vulnerable population,” LeaMond wrote.