With House Republicans prepared to take a vote Thursday on yet another version of a plan to overhaul the 2010 Affordable Care Act, attention has been especially focused on whether Obamacare's popular prohibition against denying coverage based on pre-existing medical conditions will remain in place. Republicans, from President Trump to lawmakers pushing for the bill, insist that it remains intact, just in different form. Democrats and opponents of the bill say the guarantee is gone or greatly weakened.
Here's a tweet by House Speaker Paul Ryan referring to an amendment added to the bill to attract votes:
"VERIFIED: MacArthur Amendment strengthens AHCA, protects people with pre-existing conditions."
The reality is far more nuanced and complicated, as is often the case in Washington policy debates. Despite Ryan's tweet that people with pre-existing conditions are protected, there is no guarantee that they will not face higher costs than under current law. The impact of recent tweaks to the proposed legislation is especially unclear because lawmakers are rushing ahead without an assessment by the nonpartisan Congressional Budget Office. So here's a guide to the debate.
What's the issue?
Before the Affordable Care Act, insurance companies could consider a person's health status when determining premiums, sometimes making coverage unaffordable or even unavailable if a person was already sick with a problem that required expensive treatment. The ACA prohibited that, in part by requiring everyone to purchase insurance.
But that "individual mandate" was unpopular and Republicans would eliminate that requirement in their proposed American Health Care Act. As a replacement, the AHCA initially included a continuous coverage provision that boosted insurance rates by 30 percent for one year if he or she has a lapse in coverage.
As part of an effort to attract more votes, Republicans have added an amendment, crafted by Rep. Tom McArthur, R-N.J., that instead allows states to seek individual waivers from the law. One possible waiver would replace the continuous coverage provision so that insurance companies for one year could consider a person's health status when writing policies in the individual and small group plan markets. Another possible waiver would allow the state to replace a federal essential benefits package with a more narrowly tailored package of benefits, again limited to the individual and small-group markets.
The theory is that removing sicker people from the markets and allowing policies with skimpier options would result in lower overall premiums.
Who would be affected?
If the law passed, a person generally would not be affected unless they lived in a state that sought a waiver. Moreover, they would need to have a lapse in health coverage for longer than 63 days and they would need to have a pre-existing condition. Finally, they would have to purchase insurance in the individual market, i.e., the health exchanges in Obamacare that currently serve about 18 million Americans.
Someone who got their insurance from an employer - and that's most Americans (155 million) - presumably would not be affected, though the CBO did project that under the initial version of the AHCA 7 million fewer people would be covered by employers than under current law by 2026.
Then, for a period of one year, a person who fell into this category would face insurance rates that could be based on their individual condition. But states that seek a waiver are required to operate a risk mitigation program or participate in what is called an invisible risk sharing program. Alaska currently has such a program that helps cover the bills for one of 33 conditions (such as HIV/AIDS or metastatic cancer). The individual with the condition still submits bills to the insurance company, which then turns around and bills the state. But then the insurance company does not consider the cost of this care as part of its calculation for premiums to other individuals in the state.
All told, the AHCA would allot $138 billion over 10 years for a variety of funds that would seek to keep premiums lower or to assist with cost-sharing. Just this week, $8 billion over five years was added to the pot to woo wavering lawmakers, with the idea that the additional funds could be used for so-called high-risk pools. Many states had such pools to help people with pre-existing conditions before the ACA. But the proposal does not require a state with a waiver to set up such a pool.
What could go wrong then?
There are many uncertainties about this path. The health insurance market has a lot of churn, so many people may experience a gap in coverage of just a few months. One estimate, by the Commonwealth Fund, indicated that 30 million adults would have had such a gap in 2016, potentially exposing them to a surcharge or being placed in a high-risk pool. On top of that, the Kaiser Family Foundation estimated that 27 percent of the people in the individual market have existing conditions that would have been uninsured before the ACA.
The AHCA eliminates cost sharing and offers a stingier tax credit to defray premium costs, likely resulting in higher overall health costs that may make insurance unaffordable for many people. (The CBO projected that 24 million more people would be without health insurance than under current law by 2026.)
Then, if people get sick, they may suddenly find themselves for a year being priced on their illness if they live in a state that sought a waiver. Depending on the approach taken by a state, some people might find it difficult to keep up their coverage for a full year before they qualify for prices at the community rate.
A big question is whether the funding to cover these folks is adequate. High-risk pools were big money losers and underfunded in the pre-Obamacare days, even though many had restrictions, high premiums and waiting lists. A $5 billion federal pool, established by the ACA as a bridge to the creation of the exchanges in 2013, covered about 100,000 people but was suspended when it ran out of money.
The Center for American Progress, a left-leaning group that opposes the AHCA, produced an analysis that indicated that even with the additional $8 billion, the maximum enrollment the AHCA's funds would cover is about 700,000 people. If just 5 percent of the people currently in the individual market ended up in high-risk pools - and all states sought a waiver - that would overwhelm the proposed funding.
When states had high-risk pools, people in those pools represented just 2 percent of the non-group health insurance participants. But given the limitations of those funds, that percentage may not be a good guide for what would happen under the AHCA.
Whenever health-care laws are changed, there are unknown and unintended consequences. The current system does not take into account a person's health status when assessing premiums. But, as a Brookings Institution analysis suggested, under the AHCA's provisions, healthy people might have an incentive to join plans based on health status. That would leave sicker people in the community rated plans, which in turn would face higher premiums. Over time, that could make the community rating meaningless. Another possible outcome: If the pool of money is used to pay insurance companies for the difference in costs for patients with pre-existing conditions, there may be little incentive for companies to keep their prices low; the difference would be made up by U.S. taxpayers.
The bottom line
When it comes to health care, readers should be wary about claims that important changes in health-care coverage are without consequences and that people are "protected" - or that the changes will result in massive dislocation and turmoil. There are always winners and losers in a bill of this size. In this case, if the bill ever became law, much would depend on unknown policy decisions by individual states - and then how those decisions are implemented.