In recent weeks, the Senate has launched a process for revising the House-passed bill to repeal the Affordable Care Act (ACA) that, due to its extreme secrecy, independent observers have described as “a situation without precedent” for major health legislation.
The Senate’s changes to the House-passed health bill do not change the fact that the bill would take away coverage from tens of thousands of Alaskans and make coverage worse or less affordable for thousands more. As with the House bill, Alaska may be the single most harmed state under the Senate bill’s policies.
The Senate health bill not only shifts huge costs to states by capping and cutting federal Medicaid funding — thereby forcing states to raise taxes or cut other areas like education to maintain their Medicaid programs — but makes it harder for states just to sustain their current Medicaid spending by restricting state taxes on health care providers. Every state except Alaska uses provider taxes to help finance Medicaid. (See Table 1.)
The House-passed health care bill (the American Health Care Act) slashed subsidies that help people afford individual market coverage, increasing out-of-pocket costs by thousands of dollars for people who get their coverage through the Affordable Care Act (ACA) marketplaces.
This week at CBPP, we focused on health care, the federal budget and taxes, food assistance, and jobs.
The Law Library staged a mock appeal for the Shakespearean character, Shylock, from the play, The Merchant of Venice. A full re-cap of the mock trial (including video!) is forthcoming, but we wanted to quickly share with you a scene from the event.
Gene Gulland, counsel for Antonio, stands at the lectern and listens to a question from the chief judge for the panel. Teresa Miguel-Stearns represented Portia, and Michael Klotz represented Shylock. The judges (L-R) were Micaela DelMonte, Richard Schneider, U.S. Supreme Court Associate Justice Ruth Bader Ginsburg, Connie Morella, and Suzanne Reynolds.
The Senate Republican bill to repeal the Affordable Care Act would (like the House bill) fundamentally restructure Medicaid by converting its federal funding to a “per capita cap” that would grow more slowly than actual Medicaid per-beneficiary costs, and states would likely have to make even deeper cuts to Medicaid services and eligibility under these caps beginning in 2025. Now we’ve learned that the Senate bill would penalize some states with Medicaid costs above the national average even more.
Mary Agnes Carey, a senior correspondent at Kaiser Health News, joined Lisa Desjardins and Hari Sreenivasan of the PBS NewsHour to discuss the legislation released by Senate Republicans Thursday to overhaul the federal health law.
To enroll in health plans sold in the Affordable Care Act (ACA) marketplaces, individuals must verify that they are U.S. citizens or have an immigration status that allows them to live in the United States. The Senate health bill would close the door to many immigrants with lawful immigration status who want to buy insurance plans in the marketplaces. It goes even further than the already harsh House-passed bill to repeal the ACA in preventing people who are in the United States lawfully from obtaining health insurance.
Having long decried the failings of the Affordable Care Act, Senate Republicans are purporting to fix one of its loopholes with their newly unveiled health plan. The so-called coverage gap left more than 2.5 million people living below the poverty line of $11,880 for an individual ineligible for Medicaid or financial assistance to buy insurance — even as higher earners got subsidy checks to buy theirs.
But experts say the fix, which looks fine on paper, is a mirage.
In fairness, the loophole was essentially created by Republicans and others when a Supreme Court decision meant that states were no longer required to expand Medicaid.
The Affordable Care Act offered help paying premiums to people earning between 100 to 400 percent of the poverty line, under the assumption that those under the poverty line would be covered by Medicaid.
So when 19 states decided not to expand Medicaid, millions of Americans were left in the coverage gap because they didn’t qualify for Medicaid and couldn’t afford private insurance.
As a remedy, the Senate bill would offer federal tax credits to help pay for insurance premiums for anyone earning between 0 and 350 percent of the poverty level (up to about $42,000 for an individual) starting in 2020. (Note that the upper ceiling is somewhat lower than that stipulated by the ACA.)Use Our ContentThis KHN story can be republished for free (details).
But health law experts caution that this coverage gap fix for these very low earners would likely be largely undercut by two other changes in the bill.
First, the Senate’s plan would shift the calculation for subsidies. The ACA required that premium subsidies be linked to the price of a category of health insurance that was a kind of minimum standard for Obamacare and covered 70 percent of health costs on average — called a silver plan under Obamacare nomenclature. The Senate would instead tie the subsidy to the more bare-bones bronze plans, which cover on average only 60 percent of health costs.
Although low earners might qualify for subsidies to buy insurance, making coverage an option, they would likely have a hard time using the plans because bronze plans generally have higher deductibles and copayments.
In addition, the legislation in 2019 would discontinue a second ACA subsidy — the cost-sharing reductions offered to anyone earning less than 250 percent of the poverty level. These payments help cover out-of-pocket expenses. So even if marketplace customers got subsidies to help cover their premiums, their out-of-pocket costs could be too expensive and would likely keep them from using or buying coverage.
Gary Claxton, director of the Health Care Marketplace Project at the Kaiser Family Foundation, said expanding subsidies doesn’t mean the poor will find affordable coverage. “It will give people plans that are very difficult to use at their income levels,” he said, noting the coverage will likely have deductibles of over $6,000 a year. (Kaiser Health News is an editorially independent program of the foundation.)
Another factor that experts noted is the Senate plan would phase out the Medicaid expansion.
Theoretically, people affected by the end of that program could get federal subsidies to buy coverage under the Senate plan.
But experts say the benefits would likely not be as good. That’s because Medicaid typically provides services such as transportation to medical appointments and home health care, said Chiquita Brooks-LaSure, an insurance expert with the consulting firm Manatt Health.
Andy Slavitt, who oversaw the health law for the final years of the Obama administration, said that despite the fix, options for very-low-income people would be worse under the measure announced Thursday, eliminating Medicaid and moving people to bare-bones plans, with skimpier benefits.
“That’s the aim,” he said.
The Senate Republican health bill, like the House-passed bill, would convert Medicaid to a per capita cap, but it would cut Medicaid even more deeply and pose an even greater threat to coverage for all Medicaid beneficiaries — including children.
Hospitals in states that expanded Medicaid coverage to low-income adults under the Affordable Care Act (ACA), particularly those in rural areas, have fared significantly better than hospitals in non-expansion states, based on recent published and unpublished research by the Urban Institute. Since 2013, uncompensated care costs have fallen by 1.7 percentage points more, and Medicaid revenue as a share of total revenue has risen by 2.9 percentage points more, in hospitals in expansion states than those in non-expansion