On Monday, Republican leadership in the House of Representatives moved forward with two bills to “repeal and replace” the Affordable Care Act (ACA).
The bills, though, are far from a full repeal, which may mean Republicans recognize that the ACA wasn’t all bad.
“There are so many things about the ACA that did work well,” Kurt Mosley, vice president of strategic alliances at Merritt Hawkins, Staff Care, told Healthline. “And it’s a lot cheaper to remodel a house than it is to tear it down and rebuild it back up again.”
The main effects of the legislation are on the ACA provisions for making health insurance more affordable as well as individual and employer mandates, taxes, and reforms to Medicaid.
However, the bills keep in place several popular parts of the ACA, including requiring insurers to cover preexisting conditions, maternity care, and preventive services; allowing children to stay on their parents’ insurance until age 26; and prohibiting annual or lifetime coverage limits.
So the issue is far from over.
But here is a look at who could be affected by the legislation as it stands today.
Millions could lose coverage
Since 2010 more than 20 million people gained insurance coverage as a result of the ACA.
This resulted from subsidies to offset the cost of premiums, state health insurance exchanges offering insurance, and the individual mandate.
The last one required most people to obtain health insurance or face tax penalties. This was to help keep premiums affordable for older, sicker people.
But many young people still opted to pay the penalty and go without insurance.
“The penalties just weren’t onerous enough for the individual mandate,” said Mosley. “There’s got to be a different incentive for younger people to sign up.”
The Republican legislation will try to entice people to keep continuous coverage by charging them a 30 percent surcharge if they let their coverage lapse and then sign up again.
The mandate requiring larger employers to provide affordable health insurance for their employees would also be repealed.
Also gone are the ACA income-based subsidies.
These would be replaced by tax credits ranging from $2,000 for young adults to $4,000 for older adults.
But it’s not necessarily an even swap.
“The ACA offered subsidies at a higher rate than the proposed AHCA legislation, which uses a sliding scale of tax credits. This change would most impact poor, older adults,” Michael Topchik, national leader for the Chartis Center for Rural Health, told Healthline.
This change, say analysts, could result in millions of people losing coverage.
The American Medical Association echoed concerns about the potential loss of coverage.
The group emphasized that tax credits need to “be sufficient to enable one to afford quality coverage” and tied to a person’s income to make better use of taxpayers’ money.
Coverage is important because it allows people to seek earlier treatment from primary care doctors rather than needing more expensive critical care later.
“I think we have to create a plan that makes coverage more affordable and expands the choice,” said Mosley, “but doesn’t drive Americans to the emergency room.”
Older adults and those with low incomes impacted
In particular, the loss of subsidies would impact people with low incomes, and Americans in their 50s and 60s, who could face higher premiums.
The Republican plan would allow insurers to charge older Americans five times as much for premiums as they do their youngest customers. Under the ACA, this was capped at three times.
“Before people even reach retirement age, big insurance companies could be allowed to charge them an age tax that adds up to thousands of dollars more per year,” Nancy LeaMond, AARP’s executive vice president, said in a statement.
The lobbying group for older adults also blasted the legislation’s provisions for reducing federal funding for Medicaid.
All of these changes would especially impact Americans in rural areas.
“The repeal of the individual mandate may leave fewer rural patients — who represent some of the older, poorer, and sicker members of our population — without health coverage in the future,” said Topchik.
This could increase the strain on rural hospitals, which have been closing at an alarming rate.
“I have little doubt that this will mean fewer may be able to afford health coverage,” said Topchik, “which would ultimately increase the burden on rural providers.”
Two key healthcare changes pushed by President Trump, though, are not included in the bills — reigning in rising costs of prescription medications and allowing people to purchase insurance across state lines.
Whatever the bills look like when they make it through the House and Senate, some experts are hoping that the changes are worth the effort.
“If it doesn’t cut costs and it doesn’t improve healthcare coverage and make our patient population better, why change it?” said Mosley.