The House of Representatives on Thursday passed the American Health Care Act, a revived (and revised) version of the Republican health-care bill that was pulled in March. This time, the bill included several provisions that will likely affect health coverage for people with pre-existing conditions, estimated to be about a quarter of the adult, non-elderly population.
Under Obamacare, insurers had to charge people the same amount, regardless of their health status. The AHCA would change that, allowing states to apply for waivers to charge sicker people more if those people had a gap in their insurance coverage. Those states would then get $138 billion over 10 years to help defray costs for sick people by creating high-risk pools, among other things.
The idea behind this provision is that it would make health insurance cheaper for people who are relatively healthy, while sick people would be in their own, subsidized risk pool. As they debated on the House floor Thursday, Republican members consistently assured their audience that their bill would still protect pre-existing conditions.
However, in recent days, some researchers, health advocates, and journalists have raised questions about the bill’s provisions, suggesting they might erode those protections in the end:
- The money for the sick people might not be enough: The $138 billion includes $8 billion over five years to set up “high-risk pools” for sick people. As The New York Times’ Margot Sanger-Katz and Reed Abelson point out, $8 billion could be plenty—or it could not be enough by a long-shot. It all depends on how many states apply for the waivers and set up high-risk pools. But because the money is tied to the waivers, some argue the bill incentivizes states to waive the Obamacare rules and go for the high-risk pools instead.
What’s more, the money is only guaranteed for five years. And because states could also opt out of Obamacare’s list of essential health benefits, certain types of drugs or procedures could be excluded from basic health-care plans, in effect making certain conditions, such as pregnancy or mental health beneftis, very expensive to cover.
- States could use their high-risk pool money for something else: According to a recent Health Affairs article by Tim Jost, a professor at the Washington and Lee University, states could use their chunk of the $138 billion to set up a risk pool. Or they could just use it to subsidize insurance in other ways, like by paying insurers to offset the cost of sick patients. As Andy Slavitt, the former acting director of the Centers for Medicare and Medicaid Services, put it on Twitter, “The $ can go to subsidize healthy people anyway.”
- People on employer plans could be affected, too: Before Obamacare, 59 percent of people on employer plans had lifetime limits on coverage, and those could be back if this bill becomes law. Obamacare essentially barred employers from putting limits on care for 10 “essential health benefits,” or must-have procedures and services. Because of a strange administrative quirk, employers were allowed to pick from any state’s list of benefits—a meaningless provision, since all states were required to have the same benefits under Obamacare.
But as Stephanie Armour and Michelle Hackman pointed out in the Wall Street Journal, the House bill allows employers to pick any state to “match” in terms of benefits—including one that waived the benefits requirements. In that way, people who get insurance through work might once again be exposed to high out-of-pocket costs or limits on what their insurance companies will pay. For example, if a company in Ohio decided to match Delaware, and Delaware stopped requiring prescription-drug coverage, the Ohio company could impose a limit on prescription-drug coverage for employees. Though some health experts told the WSJ that few employers would do this—they want to attract good employees, after all—it could become a cost-saving measure companies turn to in desperate times.
Ultimately, it remains to be seen just how many people with pre-existing conditions will be affected by the AHCA, since lawmakers did not wait on a score from the Congressional Budget Office before voting on it. The CBO estimated that an earlier version of the bill would leave 24 million more people without insurance after 10 years.
President Trump has repeatedly promised that Republicans would, in their health-reform efforts, protect people with pre-existing conditions. This bill seemingly attempts to do that, but whether it will in practice is another story.
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