The Senate Republicans’ Better Care Reconciliation Act would significantly affect health coverage for many Americans, whether through the individual insurance market or Medicaid. Here are a few examples of how:
* A 44-year-old breast cancer survivor, who is self-employed and makes too much to qualify for a premium subsidy under the Senate bill, could face serious problems, according to Kirsten Sloan, vice president for policy at the American Cancer Society Cancer Action Network.
Because the Senate legislation would maintain preexisting condition protections, she couldn’t be denied coverage by an insurer and wouldn’t face higher premiums because of her illness. But states would be allowed to waive “essential health benefits” — 10 categories of benefits such as hospitalization and prescription drugs that the Affordable Care Act required to ensure quality coverage. Without guaranteed benefits, Sloan said, the cancer survivor might end up with a plan that didn’t provide the care she needs.
In addition, Sloan noted, insurers would be able to set annual or lifetime limits on benefits.
* A 27-year-old man receiving drug treatment through Medicaid because his state expanded its program under the Affordable Care Act would be in considerable danger of losing that critical service, although not immediately.
The Senate bill provides $2 billion in fiscal 2018 for substance abuse treatment and recovery, but eventually it would take away much more by rolling back Medicaid expansion in 2020, capping federal payments to states and allowing them to change what qualifies as an essential service. Right now, all insurers and Medicaid must offer drug treatment benefits that are on par with their benefits for physical conditions.
If this man’s state decided that substance abuse treatment was no longer an essential service, coverage for that care could be eliminated.
“How can we possibly cut back health insurance at a time period when we have an epidemic [of drug addiction] spreading across the country?” asked Gary Mendell, founder of Shatterproof, an organization that works to improve services for substance abusers and their families.
* A severely disabled 10-year-old covered by Medicaid because he meets its strictest eligibility criteria probably would escape the state payment caps to be imposed generally on the program, according to Rachel Garfield, a senior researcher at the Kaiser Family Foundation.
But children covered via another part of Medicaid — who may have autism or asthma, for example — could see payments for care limited beginning in 2021. It is those children who appear to be the most vulnerable despite their ongoing, often serious health needs.
About 37 million children receive coverage under Medicaid, according to the American Academy of Pediatrics.
* A 59-year-old man who works as independent contractor, earning about $44,550, or 375 percent of the poverty level, qualifies for about $4,500 a year in premium subsidies for an ACA health insurance plan. Under the Senate bill, he no longer would be eligible for that help because the subsidies would end at 350 percent of the poverty line.
The man’s premiums probably would increase because insurers would be allowed to charge older customers up to five times more than they charge younger customers — compared with three times more under the ACA. Plus, his coverage would be skimpier, said Eliot Fishman, senior director for health policy at the consumer advocacy group Families USA.
*A 32-year-old woman earning below the federal poverty level in a state that did not expand Medicaid, would for the first time be eligible for subsidies to help her afford an individual health insurance plan. Based on an income of $9,500, she would have to pay only 2 percent of her earnings ($190 annually) toward plan premiums. But her out-of-pocket costs, including her deductible and copays, are likely to be very high, running about $7,000, according to experts.
“This is essentially meaningless for a low-income person,” said Fishman, of Families USA. “I would describe it as a cruel joke.”
* An 81-year-old woman in a nursing home, enrolled in both Medicare and Medicaid, might not be affected in the near term. But that could change once federal spending caps on Medicaid kick in beginning in fiscal 2020. At that point, the squeeze on states would intensify.
The exact impact would depend on states’ response to the financial pressure, according to Tricia Neuman, senior vice president at the Kaiser Family Foundation. If, for example, states cut payments to nursing homes, the quality of care could be hurt, she said. And it is possible that states could tighten eligibility rules so fewer people would be able to get nursing-home coverage.
The states that would have the toughest time are those with the fastest-growing number of the oldest and most expensive seniors — those age 85 and up. Medicaid pays the bills for about two-thirds of nursing-home residents.