House Republicans, eager to upend the Affordable Care Act (ACA), have passed a bill that independent arbiters such as the Congressional Budget Office say would increase the number of uninsured by millions, cut Medicaid by $800 billion, and raise premiums and deductibles — especially for those with preexisting conditions. But if this legislation, in its current form, is eventually enacted, the fallout won’t come immediately or all at once. It’s likely to take place over several years, in a sequence of events affecting tens of millions of people. Here’s a glimpse of how the next few years might unfold under the American Health Care Act (AHCA) if it becomes law:
- Summer 2017: In their annual report on the state of Medicare, the program’s trustees announce that, mainly because it rolls back taxes on high-income households that fund the program, the AHCA will accelerate the depletion of Medicare’s Hospital Insurance Trust Fund as less revenue comes in. Meanwhile, because the AHCA eliminates the penalty for not having coverage, insurers announce that they’re canceling plans or sharply raising premiums for 2018 out of fear that more healthy people will opt not to get insurance, leaving plans overloaded by sick people who are more expensive to cover.
- Nov. 1, 2017: “Open enrollment,” the period when potential enrollees can sign up for health insurance plans for the following year, begins for the first time under the AHCA. People logging onto (let’s call it) Trumpcare.gov find that they’ll pay substantially higher premiums compared with prior years, and many of their plans are no longer available. With insurers now permitted to charge older people as much as five times what they charge younger individuals — instead of three times or more under Obamacare — older Americans see their premiums soar. What’s more, the AHCA’s tax credits for many older people are less generous than the ACA’s were, so they have less help with payments.
- Nov. 1, 2018: Open enrollment begins again, and now states — under pressure to stabilize their insurance markets — are letting insurers charge people with preexisting conditions more, so long as they receive an easily obtainable federal waiver. In states with waivers, people signing up on Trumpcare.gov are asked for their medical history, and they face much higher premiums or must buy coverage through separate high-risk pools if they have preexisting conditions.
- Spring/summer 2019: The 31 states, plus the District, that expanded Medicaid under the ACA will begin bearing much more of the cost in 2020, so most or all enact legislation to close their expansions to new enrollees — or else raise taxes or make painful cuts elsewhere — as they finalize their budgets for the upcoming year, marking the first step toward ending an expansion that has covered more than 11 million people. States also tighten Medicaid eligibility requirements and reduce benefits and provider payments. Meanwhile, states will now have to cover any unexpected Medicaid costs because of a health crisis without federal help, forcing them to raise taxes or cut other services if they’re going to respond.
- Nov. 1, 2019: Millions of consumers face additional, sharp increases in what they must pay to get coverage, as well as for deductibles and out-of-pocket costs, as the ACA tax credits are replaced with less-generous ones and “cost-sharing subsidies” are repealed without any substitute. Consumers in the marketplace will receive an average of $2,200 less in premium tax credits, according to forecasts from the Center on Budget and Policy Priorities; in 12 high-cost states, the average drop will be at least $3,000. For older and sicker consumers, the price tag is even higher. Meanwhile, deductibles and other out-of-pocket costs rise by an average of $1,200 per consumer. For example, a low-income 60-year-old in West Virginia ends up paying nearly $12,000 more per year for insurance, while her other out-of-pocket costs increase by an additional $1,400.
- In addition, consumers in several states find that their insurance no longer covers “essential health benefits,” such as maternity care and mental health services; doesn’t meaningfully cap out-of-pocket costs; and effectively restores pre-ACA annual and lifetime limits. Women in these states discover that, just like before the ACA, they must pay more because of the added cost of maternity coverage.
- Jan. 1, 2020: In most states, the Medicaid expansion is closed to new enrollees. Millions of people who in 2017 benefited from the expansion have cycled off the program, even though they’ll need coverage again if they lose a job or an employer cuts their hours.
- 2020 and beyond: The number of uninsured Americans continues to rise as fewer people enroll in the individual market. The Medicaid expansion effectively ends by 2024. States have to make deeper cuts to their Medicaid programs each year because of shrinking federal funds. People who are lower income, have preexisting conditions or are older disproportionately find themselves without coverage and forgo needed care.
House members passed a bill they had only a few days to review. Perhaps, knowing all the above, the Senate will be more judicious.