Repeal Without Replace Too High?

NPR Policy-ish  Health Care: Were the Risks of Repeal Without Replace Too High?   July 18, 201711:34 AM ET  Alison Kodjak, Alyson Hurt, Giselle Grayson https://www.npr.org/sections/health-shots/2017/07/18/537868412/health-care-the-risks-of-repeal-without-replace

Updated at 2:54 p.m. ET

After the Senate's attempt to replace the Affordable Care Act collapsed Monday, Republican leaders immediately began talking about repealing the health care law in hopes of coming up with a replacement later.

But by midafternoon Tuesday, Senate Majority Leader Mitch McConnell's plan to hold a vote on a repeal-only bill had faltered, too.

Sen. Shelley Moore Capito, R-W.Va., was the first to say that she wouldn't support the repeal effort because of the threats it poses to people's coverage. She was followed by fellow Republican Sens. Susan Collins of Maine and Lisa Murkowski of Alaska. [Coverage for Maternity, Women and Child services will be disproportionately cut back which would hurt in turn economic viability of hospitals and health care clinics in rural areas and adversely affect the employment provided to people in these areas, convenience and efficiency and costs of care by curtailing preventive care and consistent engagement in Chronic Diseases management.VM}

"I did not come to Washington to hurt people," Capito said in a statement. "I have serious concerns about how we continue to provide affordable care to those who have benefited from West Virginia's decision to expand Medicaid."

The replacement bill's language is based on the repeal bill that that passed by the House and Senate in 2015 but was vetoed by President Barack Obama.

Here's how the repeal would have changed the Affordable Care Act, compared with the House and Senate bills.

People under 26

Affordable Care Act (Obamacare)

Can get insurance through a parent’s plan or buy independently.

House: American Health Care Act

Stays the same.

Senate: Better Care Reconciliation Act

Stays the same.

Senate: Repeal-only {proposed}

Stays the same.

Adults under 65

Affordable Care Act (Obamacare)

Can buy insurance on health exchanges, with tax credits and subsidies if they meet income requirements up to 400 percent of poverty level. Cost of insurance is based on tobacco use and age, with the people nearing 65 paying no more than three times what the youngest pay. Premiums can’t cost more than 9.5 percent of income. Those with very low or no income qualify for Medicaid.

House: American Health Care Act

Will see tax credits to pay premiums based on age, not income, and that max out at $4,000, much less than under the ACA. The oldest people under 65 can be charged five times more than the youngest, and maybe more depending on state rules. Medicaid cut after 2020.

Senate: Better Care Reconciliation Act

The CBO report says 22 million people would lose health insurance over the next 10 years, with people between 50 and 64 disproportionally impacted. The oldest people under 65 would pay five times more than younger people on the exchanges. Subsidies to help pay for insurance would be less and end at incomes of 350 percent of poverty level. Federal contributions to Medicaid start to decline in fiscal year 2020. July 13 update: New draft would let subsidies be used to buy plans that offer only catastrophic care and would let consumers use health savings accounts to pay premiums.

Senate: Repeal-only {proposed}

The bill first put forth in 2015 would repeal major provisions of the Affordable Care Act, including the federal Medicaid expansion funding, the premium tax credits and cost-sharing subsidies, the individual mandate and the employer mandate. The CBO said that 32 million people would lose health insurance by 2026 under the bill, HR 3762. It also said that premiums on the exchange would increase 20 percent to 25 percent the year after enactment. In addition, roughly 10 percent of the population would live in areas where there would not be any insurer in the individual market.

Low-income nursing home residents

Affordable Care Act (Obamacare)

Skilled nursing care covered by Medicare up to 100 days per illness. Medicaid is available based on income.

House: American Health Care Act

Skilled nursing care covered by Medicare up to 100 days per illness. Medicaid services or payments to nursing homes could be cut as states see federal funding decline.

Senate: Better Care Reconciliation Act

Skilled nursing care covered by Medicare up to 100 days per illness. Medicaid coverage for nursing home services and payments to nursing homes could be cut as federal payments to states decline.

Senate: Repeal-only {proposed}

Skilled nursing care covered by Medicare up to 100 days per illness. Medicaid services or payments to nursing homes could be cut as states see federal funding decline.

People with pre-existing medical conditions

Affordable Care Act (Obamacare)

Coverage cannot be denied or cost more.

House: American Health Care Act

States can get permission to let insurers charge more for some pre-existing conditions and to exclude some people altogether. States would have access to federal money to help those with expensive policies or conditions.

Senate: Better Care Reconciliation Act

Insurance companies would be required to accept all applicants regardless of health status. But the draft bill lets states ask permission to reduce required coverage, also called “essential health benefits,” which would give insurers some discretion over what they offer in their plans. That could result in “substantial increases” in costs for people who want those services, according to the CBO. If a benefit is no longer classified as essential, insurers could impose annual and/or lifetime limits on what they spend on patients for that benefit. And caps on the annual out-of-pocket costs for patients would no longer apply. July 13 update: New language would end protections for people with pre-existing conditions by letting insurance companies sell plans that don’t include the ACA’s essential health benefits, if an insurer also offers a plan with those benefits on the exchange. Analysts and insurers warn that this could create two markets, one for sick people who need more benefits and one for healthy people who need fewer. That would drive the cost of insurance much higher for people who want more benefits, including people with pre-existing conditions. Subsidies would be available for lower-income people to buy a comprehensive plan, but out-of-pocket costs would still go up for them, probably by a lot.

Senate: Repeal-only {proposed}

Insurance companies would be required to accept all applicants regardless of health status. The 10 ACA-mandated essential health benefits would also remain in place. But the provisions that repeal the individual and employer mandate would mean that healthier people would likely drop insurance and prices would rise for consumers who continued to purchase it — in other words, sicker people. The CBO estimates prices would be about 50 percent higher in the first year after subsidies would be eliminated and double within 10 years. Within 10 years, the report says, fewer than 2 million people would have insurance on the exchange.

People who go to Planned Parenthood

Affordable Care Act (Obamacare)

Federal programs reimburse for most Planned Parenthood services.

House: American Health Care Act

A one-year block would be placed on federal reimbursements for care provided by Planned Parenthood.

Senate: Better Care Reconciliation Act

A one-year block would be placed on federal reimbursements for care provided by Planned Parenthood. The CBO estimates 15 percent of women would lose access to family planning care, increasing birthrates and Medicaid spending for childbirth and children’s insurance. But those increases would be offset by Planned Parenthood cuts.

Senate: Repeal-only {proposed}

A one-year block would be placed on federal reimbursements for care provided by Planned Parenthood

People with disabilities

The majority of Medicaid dollars go to people with disabilities

Affordable Care Act (Obamacare)

May qualify for Medicare and also Medicaid.

House: American Health Care Act

May qualify for Medicare and also Medicaid. But services covered by Medicaid could be cut as federal funding to states declines over time. {$ 800 Billion cut from Medicaid over time.VM}

Senate: Better Care Reconciliation Act

May qualify for Medicare and Medicaid. But services covered by Medicaid could be cut as federal funding to states declines over time. The CBO report suggests that by 2026, Medicaid enrollment would fall by more than 15 million people. {$ 700-800Billion cut from Medicaid}

Senate: Repeal-only {proposed}

May qualify for Medicare and Medicaid. The elimination of federal Medicaid expansion funding could have ripple effects to people with disabilities as states would have to decide whether to make up lost funding, trim services or limit who can get Medicaid. Laws would remain on the books that Medicaid would need to cover those with disabilities, but in some states, people could face long waits (months to years) to get those benefits.

People who use mental health services

Affordable Care Act (Obamacare)

Covered by all plans under essential health benefits.

House: American Health Care Act

Could lose coverage in states that get waivers from covering essential health benefits.

Senate: Better Care Reconciliation Act

States could request waivers to opt out of requiring essential health benefits. If a state opted out of coverage for mental health care, insurance that includes mental health care coverage could become “extremely expensive,” the CBO says.

Senate: Repeal-only {proposed}

Mental health coverage would remain intact as one of the 10 essential health benefits. However, without the mandate that people must have insurance, it is likely that only people who require robust coverage would continue to purchase it, and prices would go way up for those plans on the individual market. Essential health benefits would be done away with in Medicaid.

Working poor on Medicaid

Affordable Care Act (Obamacare)

Thirty-one states and the District of Columbia offer expanded Medicaid coverage.

House: American Health Care Act

Federal funding for Medicaid expansion phases out, potentially affecting millions of people who are currently enrolled under the expansion.

Senate: Better Care Reconciliation Act

Federal funding for Medicaid expansion phases out between 2021 and 2023. In addition, eight states have a trigger clause — if the federal matching rate declines below the ACA-promised rates, the expansion goes away immediately in Arkansas, Illinois, Indiana, Michigan, Montana, New Hampshire, New Mexico and Washington. Further reductions would start in 2025. In a separate provision, states could impose a work requirement on recipients. Most able-bodied adult Medicaid recipients already work.

Senate: Repeal-only {proposed}

Federal funding for Medicaid expansion would phase out over two years. Eight states have a trigger clause. If the federal matching rate declines below the ACA-promised rates, the expansion goes away immediately in Arkansas, Illinois, Indiana, Michigan, Montana, New Hampshire, New Mexico and Washington.

The wealthy

Affordable Care Act (Obamacare)

Pay extra taxes to support ACA.

House: American Health Care Act

The bill would repeal ACA taxes on corporations and cut taxes for the wealthy by about $592 billion.

Senate: Better Care Reconciliation Act

Like the House bill; would repeal ACA taxes on corporations and the wealthy that pay for insurance subsidies. That would add up to about $563 billion in tax cuts over 10 years, according to the CBO. July 13 update: The revised version keeps some of the ACA’s taxes on higher-income people. But the permission for flexible spending accounts to be used for premium payments will be a tax advantage for those who can afford to put money aside in those accounts.

Senate: Repeal-only {proposed}

The bill repeals taxes on corporations and the wealthy. According to the CBO’s June 2015 estimate, that would add up to $631 billion in tax cuts over 10 years

This chart was last updated on July 18, 2017.

After Trump was elected in November, Republicans in Congress considered reviving the so-called "repeal and delay" strategy and rejected it. The risks that made it so unpalatable then may have doomed it now.

Here are some of the biggest impacts with straight-up repeal:

1. The Cost of Insurance Premiums Would Skyrocket

While McConnell and Trump called this plan a straight repeal of the Affordable Care Act, it would in fact have left many parts of the law in place. That is because under Senate rules, legislators can only repeal the parts of the law that have a budget or tax impact.

The individual mandate that everyone, healthy or sick, must buy insurance would disappear. But the rule that insurers must write policies for anyone, no matter their health status, would stay. [This is the perfect recipe for blowing up coverage for all by sparking a death spiral.VM]

"Insurers would have to take people with pre-existing conditions, but the sense is that healthy people without that mandate wouldn't sign up," says Larry Levitt, vice president of the Kaiser Family Foundation, a health care research organization. "So, insurers, with that kind of uncertainty, would immediately raise rates."

The Congressional Budget Office analyzed the 2015 legislation in January and said that if it was to pass, insurance premiums would rise 20 percent to 25 percent in the first year. Under McConnell's plan, that would have been 2018.

1. Millions Would Lose Their Insurance

Those high prices would have driven millions of people out of the insurance market.

The same CBO report estimated that the number of people without insurance would increase by 18 million in the first year if legislation similar to the 2015 bill became law.

That is almost the same number of people who gained insurance in the seven years since the Affordable Care Act passed. [In one- year post repeal all the gains in coverage will be wiped out for 18 million fellow Americans. The categories are listed.VM]

About 10 million people would have lost coverage because they would drop their individual plans,

5 million would be dropped from the Medicaid rolls and

3 million would lose their employer-provided coverage, the CBO said.

It also said that within 10 years, 32 million more people would be without insurance than if the ACA stayed in place.

1. Insurance Markets Would Unravel

Rising rates and fewer people in the market are the two ingredients for the much-invoked "death spiral." That would occur if rates rise so much that nobody can afford insurance and the entire market collapses.

And that is what the Republican's proposed repeal of the Affordable Care Act, or Obamacare, would have done, according to multiple health care analysts.

Robert Laszewski, president of Health Policy and Strategy Associates, a consulting firm, says a repeal and delay "would just cause more market calamity without a known replacement."