When Republicans in the House voted Thursday to repeal the Affordable Care Act and replace it with their own version, it marked a sea change in what Americans can expect for health insurance coverage. That is, if the plan gets through the Senate. The changes in the House plan are profound.
The House Republican health care bill, called the American Health Care Act, marked a victory for President Donald Trump and House Speaker Paul Ryan, R-Wisconsin, who shepherded the measure through a contentious chamber, after pulling an earlier version last month for want of sufficient votes.
"I went through two years of campaigning and I'm telling you, no matter where I went, people were suffering so badly with the ravages of Obamacare," President Trump said at a ceremony in the White House Rose Garden after the bill passed. Mr. Trump decried higher premiums and deductibles under his predecessor's signal legislative achievement, as well as the exit of health insurers from a number of markets, limiting people's choices for coverage.
How that would work in practice is an open question. Before the ACA was enacted, 35 states established their own high-risk pools, but an analysis by the Kaiser Family Foundation showed that the results were discouraging.
Nearly all the states barred patients with preexisting conditions from pool coverage for six months to a year. Plus, premiums were 150 percent to 200 percent higher than market rates, and deductibles were high -- in 29 states, $1,000 or more, and in 10 states, $5,000 and up.
A nationwide system, backed by federal subsidies might fare better. And there may be an ancillary benefit, for healthy people. Speaker Ryan has said by shifting the risk of covering sicker people from insurance rolls to the pools, premium costs for healthier policyholders likely would drop.
Age rating. With Obamacare, insurers can charge older people more than younger -- because medical needs and expenses increase with age -- but it limits the difference in premiums to no more than three times what the young pay. Under the House bill, that would bump up to five times. The reason: Health costs for Americans in their 60s are about five times higher than for those in their 20s.
Medicaid recipients. When the Congressional Budget Office examined the original version of the House bill (it hasn't yet analyzed the version just passed), it estimated that 24 million Americans would be without health coverage a decade following the ACA's repeal. A major factor for that was the expected rollback of Medicaid expansion in the 31 states that opted for it. Under the ACA, the federal government picks up much of the tab to help poor people afford health coverage, with the states paying the rest.
The House bill would keep things status quo until 2020 to give people time to adjust. From that point, no new Medicaid enrollees would be accepted. And people who dropped a policy -- say they got a job with coverage, then lost that job -- would be forbidden reentry.
The House measure doesn't seek to do away with Medicaid funding, just curbs it. Under Obamacare, federal outlays are open-ended, but the GOP revamp would cap Washington's payments by bundling the money into block grants. That would reduce federal spending on Medicaid by $880 billion over the next decade, the Kaiser Foundation projects.
State Medicaid plans also would no longer have to cover some of Obamacare's essential health benefits, which delivers on a Republican pledge to return more control to the states.
Employer health plans. If Obamacare is replaced, even people covered under employer plans could be affected. Should states permit insurers to offer bargain plans that cover just the minimum benefits, companies might shrink what they offer employees, according to Matthew Fiedler, a health policy analyst at the Brookings Institution, in a recent article.
For instance, Obamacare bans annual and lifetime spending limits. As Fiedler put it: "In the absence of any essential health benefit standards at all, these protections would effectively disappear because they would apply to an empty set of health benefits." Other ACA rules, he noted, such as the ceiling on what patients pay for medical care each year, are linked to the minimum benefits.
Requiring coverage. The House bill would scrap the federal mandate that everyone must enroll in a health insurance program, or pay a penalty on their taxes. Liberal critics of Obamacare said the mandate doesn't charge enough to force reluctant younger people to buy a medical plan. The Congressional Budget Office believes thousands of current Obamacare policyholders would bail out if the House framework prevails.
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