Friday, May 14, 2021
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The Patient Protection and Affordable Care Act (ACA) was signed into law on March 23, 2010, by President Barack Obama. Some love it, others hate it. Now, President Donald Trump and the new administration have vowed to repeal and replace the ACA. Republican leaders are still figuring out when the repeal will take place, how extensive it will be, and what the replacement should be.
Here's what's at risk in the ACA and what it means to you. Get ready for a bumpy ride.
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Provision: Health insurers cannot deny coverage, charge more, or make coverage exclusions for people with preexisting health conditions, such as asthma, diabetes, or cancer. Because this provision doesn't involve taxing or spending, removal would require a 60-vote supermajority. Even among Trump supporters, 60% favor keeping it.[1]
If it's removed: About 27% of adult Americans younger than 65 years have health conditions that might lose them coverage in the individual market.[2] This could affect their future healthcare and your patient roster.
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Provision: Individuals and employers with 50 or more full-time workers have to buy insurance or face financial penalties. These provisions could be removed by a simple majority vote in the Senate.
These mandates are quite unpopular. About 7.5 million people had to pay a fine through their taxes for not buying insurance in 2014.[1]
If it's removed: Removal of this mandate would disrupt the individual insurance market, if popular insurance market reforms such as the requirement to cover preexisting conditions were left in place. As long as the preexisting conditions requirement is in place, healthy people could wait until they were sick to buy insurance, leaving insurers with too many sick people who have more expenses.
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Provisions: Under the ACA, insurers must cover 10 categories of essential benefits, including outpatient care, hospitalization, prescription drugs, preventive services, rehabilitation, lab services, maternity care, and pediatrics. Insurers are also prohibited from putting lifetime or annual payment limits on these benefits. In addition, the ACA limits age bands, meaning that there's a limit to how much insurers can charge older people compared with younger people.
If they're removed: Premiums could be lower, but coverage would be scantier. Annual or lifetime payments could be limited. Patients would be less likely to get these key services.
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Provision: Insurers must cover certain preventive services without any cost-share to the patient. These services include colonoscopies, mammography, vaccines, diabetes screening, and wellness visits, among many others.
It would be hard for Congress to repeal this measure. Because it does not involve federal spending, it would require a 60-vote supermajority in the Senate to remove it.
If it's removed: Removing this provision would remove free testing for tens of millions of people. If people are less likely to get these tests, they may seek medical treatment only when they are more seriously ill, and use hospital or emergency services.
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Provision: States get generous subsidies for expanding Medicaid eligibility to people with incomes up to 133% of the federal poverty level, and this provision opens the program to childless adults, who had previously been excluded in many states. In June 2012, the US Supreme Court made the expansion voluntary, and as of January, 18 states were not participating.
If it's removed: The expansion program has been tremendously popular, adding millions to the Medicaid rolls. Repeal would cause more than 10 million people to lose coverage, putting strains on emergency departments and federally funded community health centers, which could also lose their ACA funding through a simple majority in the Senate.
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Provision: On the ACA's state-based healthcare marketplaces, subsidies to buy insurance are available to people who have household incomes of up to 400% of the federal poverty level. There are two kinds of subsidies: one for premiums, the other for healthcare expenses.
If they're removed: Without subsidies, many of the estimated 12 million people who buy insurance would not be able to do so, or they might not adhere to prescriptions and other recommendations from doctors.
Republicans argue that many of these people could afford to pay for coverage if insurers didn't have to follow all of the ACA's strict coverage requirements, including not turning away people with preexisting conditions, providing essential benefits, and complying with age bands.
But without these protections, people would have much scantier policies. Removal of subsidies might also spell the end of healthcare marketplaces, which depend heavily on subsidies.
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Provision: The Center for Medicare and Medicaid Innovation (CMMI) is a key player in meeting the Obama administration's goal of shifting Medicare payments from fee-for-service to value-based payments, which focus on costs, quality, and outcomes. CMMI has been creating value-based payment models, such as advanced accountable care organizations and bundled payment arrangements.
If it's removed: A simple Senate majority could strip the agency of its funding, which amounted to $1.4 billion to operate in fiscal year 2015, according to a Centers for Medicare & Medicaid Services (CMS) budget report.[3]
However, if Congress removed the CMMI, it would lose potential savings of $34 billion that the agency is expect to generate from 2017 to 2026, according to a December report from the Kaiser Family Foundation.[2].
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Provision: Before the ACA, Medicare Part D coverage ended after a certain dollar amount, and drugs would be paid for only when catastrophic coverage provisions kicked in. The ACA is gradually reducing this “donut hole,” and it is expected to disappear in 2020.
A Kaiser poll showed that 71% of Trump supporters approve of the donut hole. But because this provision involves extra spending, it would probably be possible to repeal it with a simple Senate majority.[1]
If it's removed: This does not seem to be a provision that Republicans are targeting, but if they did remove the donut hole, it would affect millions of Medicare beneficiaries.
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Provisions: The ACA levies hefty taxes on pharmaceutical manufacturers, medical device manufacturers, health insurers, and wealthy citizens. These taxes have been helping to pay for the law's coverage expansions and such expenses as the CMMI.
Similarly, the ACA reduced payments to Medicare Advantage plans, managed care plans for beneficiaries that were thought to be overpaid. And it cut Medicare Disproportionate Share Hospital payments, which compensate hospitals for providing care to low-income patients.
If they're removed: Without these funds, the ACA wouldn't be able to continue its coverage expansions and other projects. Moreover, the Republicans would have less money to fund their own replacement plan, such as Paul Ryan's plan to spend $25 billion to fund high-risk pools.
If the taxes are removed, Republicans would have to double down on efforts to find savings in the Medicaid and Medicare programs.[4]
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Provision: The ACA created the Independent Payment Advisory Board (IPAB) to create savings when Medicare spending reached a certain level. The panel has the authority to make payment changes, and Congress would need a three-fifths supermajority vote to overrule it.
Owing to a slowdown in the growth of Medicare spending in the past few years, the IPAB has never been used, and its 15-member panel has not even been appointed. But the CMS Office of the Actuary has forecast that the IPAB process could be triggered this year.[5]
If it's removed: Congress would have to find another way to control federal healthcare spending, which it has failed to do in the past. In lieu of IPAB, many Republicans want to look for savings in Medicare through a complete overhaul of the program.
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What happens to the ACA is still very much in flux, but the issues about repealing each of these provisions is already clear.
What remains is for Republicans to decide on the complicated tradeoffs in dealing with each provision. These tradeoffs have to do with politics (avoiding a voter backlash), insurance (avoiding a meltdown of the market), finance (making sure they don't add to the federal deficit), and legislation (meeting the rules of the Senate).
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