Two weeks ago, Republicans in the U.S. Senate released a draft of their bill to repeal and replace the Affordable Care Act (ACA).
Since then many people have been wondering how the proposed changes would affect coverage for themselves and their families.
To answer some of these questions, let’s take a trip forward in time to see how the GOP’s post-Obamacare vision could play out.
The family depicted here is fictional, but the problems they face are felt by many Americans.
This scenario is based on the Senate’s bill as it stands now, which differs in some ways from the earlier bill passed by the House.
It’s also difficult to know how states would respond to proposed changes, particularly the Medicaid cuts.
The Senate bill is set for a vote after the July Fourth recess, so it’s possible more changes will be made to the bill as the debate continues.
Cheaper insurance, less coverage
Born and raised in Overland Park, Kan., Mark, 46, still lives in the city, at the end of a quiet cul-de-sac, with his wife and two of their three children.
His oldest son dropped out of college and now lives on his own downtown.
It’s 2020, and Mark runs an at-home consulting business and makes around $60,000 per year. Because he’s self-employed, Mark buys his health insurance through the state’s health exchange, something he started doing after ACA programs launched in 2014.
When the Republicans came up with a bill to replace Obamacare, Mark hoped it would save him money on health insurance. That’s one of the reasons he voted Republican in the last election.
But for him, not much has changed.
After the Senate’s bill was signed into law three years ago — without any major changes — Mark is still paying around $5,500 per year for insurance. Because of his age and income, he doesn’t qualify for tax credits to offset his premium.
Under the Senate bill, his cost is similar to what the Kaiser Family Foundation estimated for someone his age and with his income living in Johnson County, Kan.
Since the bill’s passage, Mark’s premiums have been creeping up every year.
One thing that changed, though, is that he now has other options for saving money on insurance.
The Senate’s bill allowed states to opt out of consumer protections for insurance — which Kansas did. After that, insurers in the state started selling plans that were cheaper, but offered fewer benefits.
Mark could choose from a wider variety of plans, including ones that have a higher deductible or cover him only for urgent medical care.
These plans could lower his monthly premium, but if he needed medical care, Mark would have to cover the full cost of care until he met his deductible. After that, he’d have to pay a larger share of his medical expenses.
Under these types of “catastrophic” plans, he also wouldn’t be covered for routine and preventative care such as seeing a doctor for a cold, minor injury, or screenings like blood pressure, cholesterol, and colonoscopies.
The other day Mark read about a study from 2017 that concluded people without health insurance are more likely to have health problems and die earlier than those with insurance.
Already middle-aged, Mark is uncomfortable skimping on insurance because he knows that seeing his doctor regularly can keep him healthy longer.
Preexisting conditions a problem
Mark’s wife, Kim, 42, works part time and also buys insurance through the state’s health exchange.
She makes much less than her husband, so she gets a tax credit — which is smaller than what she was getting under Obamacare.
Even with the tax credit, her yearly premiums went up $1,620 after the Senate bill passed.
Before Obamacare, Kim had trouble getting insurance because she has type 2 diabetes, a preexisting condition.
She was denied coverage even though her diabetes was under control, and she rarely had any serious medical costs due to her condition.
Then, Obamacare banned insurers from denying people coverage or charging them more for a preexisting condition. For Kim, that was a godsend.
The new Senate bill kept the ACA’s protections for people with preexisting conditions, but it lets states ask permission to reduce “essential health benefits.”
After the Senate bill became law, Kansas enacted this for people with diabetes and several other conditions. Insurers in the state — including Kim’s — are now able to set a cap on annual or lifetime limits for these conditions. Also gone are caps on out-of-pocket costs for patients.
Already Kim has to pay a bigger share for any medical care she receives for her diabetes.
So far, she hasn’t hit the coverage limits. But she worries that one major hospital visit due to her diabetes would put her at the cap, leaving her owing thousands of dollars in medical expenses.
Opioid addiction treatments
Mark and Kim’s 22-year-old son, Tyler, lives in the city on his own and works as a barista at a local coffee shop.
After he was in car accident while in college, Tyler developed an addiction to prescription opioids. He dropped out of school and later started using illegal opioids.
Tyler still struggles today, but for the past year he has been going to an addiction treatment program covered by Medicaid.
Under Obamacare, many states expanded Medicaid, which opened up coverage for addiction treatment programs to more adults with addictions. This included covering the cost of drugs like Suboxone that help people with addictions control their cravings and quit using.
Kansas was not one of the states that expanded Medicaid, but Tyler still qualified for Medicaid-covered treatment.
The Senate bill, though, cut billions of dollars from Medicaid. This put a cap on how much federal funding states get for each enrollee, and gave them more flexibility in how they run their programs.
To offset the state Medicaid cuts, the bill provided an extra $2 billion for opioid treatment and recovery programs nationwide. But in 2017, some experts thought that $180 billion over a decade would be needed to deal with the opioid epidemic in the United States.
In order to avoid a budget shortfall related to Medicaid, Kansas started to make it harder for people to qualify for Medicaid, including those who had qualified for it before.
Tyler received a letter from the state Medicaid office telling him that because of the new rules, he would be dropped from Medicaid.
For now, he can keep going to addiction treatment, but he’s being asked to pay more for his Suboxone, which he can’t really afford.
Already he has skipped several visits to the treatment center because he doesn’t have enough money.
Medicaid cuts affect older adults
Mark’s 77-year-old mother, Beverly, has been in a nursing home for several years. Under Obamacare, Medicaid paid much of the cost of her care.
This was not unusual. In 2017 Medicaid covered the costs for about 62 percent of seniors living in nursing homes who had low incomes and few assets. These types of services are not covered by Medicare.
The Medicaid cuts have affected Beverly — and the rest of her family.
To keep its budget balanced, Kansas reduced Medicaid payments to older adults in nursing homes or long-term care.
That means Mark has to come up with thousands of dollars more each year to keep his mother where she is now.
The other option is to move her to a less expensive facility. The nearest one, though, is 60 miles away.
Insurers charge older people more
Mark’s father-in-law, Graham, runs a bakery in Overland Park. He felt the impact of the Senate bill right after it went into effect three years ago.
Graham makes a little more than $30,000 a year, but now his yearly premium is $7,540 — a quarter of his total income. Even with the tax credits.
Under the Senate bill, insurers are allowed to charge older people five times what they charge younger people for insurance. Under Obamacare it was only three times.
Graham is 62 years old, so he still has three years to go before he can qualify for Medicare. But already his insurance premiums are eating up his retirement savings.
He may have to keep working longer just to make ends meet, but as he gets older the long days in the bakery are starting to wear him down.
Young people delay getting insurance
Mark’s nephew Matt, a healthy 28-year-old, didn’t really see much of a change with the Senate healthcare bill.
He works at a welding and machine shop that has about 60 employees.
Under Obamacare, the shop would have had to provide him with affordable insurance. The Senate bill eliminated this employer mandate, so now his employer expects employees to buy insurance through the state’s health exchange.
Matt makes almost $30,000 a year, but it would cost him more than $2,600 a year to get health insurance — a little bit more than he would have paid under Obamacare.
Which he didn’t.
Even though Obamacare penalized him for not having insurance — a few hundred bucks a year — paying the penalty was still cheaper than buying something that he never used.
Matt is saving up to buy a new car, so what’s the point?
A few years ago Matt did have insurance after he broke his leg while four-wheeling, but he dropped his coverage after he recovered.
He has thought about getting insurance again in case he gets sick. One trip to the hospital without insurance after a bad spill on his four-wheeler would blow through his car savings in a flash.
But under the Senate bill there’s now a six-month waiting period before you can sign up again if you’ve been uninsured for too long.
For now, though, Matt is banking on not needing insurance any time soon, or at least not until he buys the new car.
Pregnancy, maternity care impacted
Matt’s sister Sofía gets insurance through her employer, a small architecture firm, where she does the bookkeeping.
Like many, she thought her premiums would decrease, but they continue to rise.
Also, Kansas requested a waiver — which was approved — to drop pregnancy and maternity care from the list of “essential health benefits.” So things now are basically back to what they were before Obamacare.
Sofía and her husband have been talking about having children, but under the new bill she would have to pay a lot more out of pocket for a pregnancy. She also has to pay for her birth control and cervical cancer screenings.
She would really like to start a family, but for now she and her husband are waiting until they can afford it — and hoping that an unexpected pregnancy doesn’t derail their plans.
Wealthy score with tax breaks
With healthcare costs taking up a lot of Mark’s income, and having to pay more for his mother’s nursing home care, he is feeling pinched on all sides.
So the other day he turned to his cousin, David, for help paying all these bills … just until he can figure something else out.
David runs an import-export business and has been doing really well lately — especially after the Senate healthcare bill was approved.
The bill cut taxes on corporations and the wealthy, including repealing an Obamacare capital gains tax. Under Obamacare, these taxes had helped pay for insurance subsidies and the Medicaid expansion.
With his high income, David didn’t see much of a change in insurance premiums after the Senate bill passed. He doesn’t qualify for tax credits to reduce his premiums, but he is getting those other tax breaks.
All that doesn’t really matter because David pays about $7,000 a year for a concierge doctor. This service lets him see his doctor without having to wait weeks for an appointment. He also pays for catastrophic health insurance to cover any hospital visits or more expensive tests or treatments.
David’s business is booming, so he’s more than happy to help out his family.
But Mark feels guilty about not being able to make ends meet on his own. Things could be worse, though. Many of his friends are facing similar financial troubles, but none of them have a rich cousin to turn to.
For now, like many in his family, Mark is living from day to day, hoping that no one gets really sick.
One major injury or illness could bring everything tumbling down around them.