With Obamacare Facing Repeal, What Happens Next?

Jonathan Osborne of Louisville, Ky., was out of work and covered through the Affordable Care Act when his bladder cancer was diagnosed. "When I go back to work and have to pay something for my insurance, I won't holler and pout about it," he said. "I'll remember the time this government insurance saved my life."It looks like the beginning of the end for Obamacare as we know it. years of vowing to repeal the Affordable Care Act, as it is formally known, Republican lawmakers in both chambers of Congress have passed a bill that will make it easier to gut the law.Because they are using a special budget process, Republicans won't be able to repeal all provisions of the health law. But it's a good time to look at the major changes Obamacare brought to health care, which of those changes may disappear and what might replace them.An important note: We still don't know the details of a repeal bill, and passage is not guaranteed. But Republicans passed a similar package in 2015, vetoed by President Barack Obama, that provides a rough template. Republicans have also said they hope to make further changes through additional legislation.Insuring millionsThe health law reduced the number of uninsured Americans by an estimated 20 million people from 2010-16. One of the primary ways it did so was by creating online markets where people who didn't get insurance through work or the government could shop for a health plan from a private insurer. The law offered subsidies for Americans with lower incomes to help pay their premiums and deductibles.What would happen?The Republican bill is expected to eliminate the subsidies. This would make insurance unaffordable for millions of Americans and sharply reduce the number who buy their own health coverage.With many fewer people buying coverage, the insurance markets are likely to become increasingly unstable.Many insurers could stop offering policies, and the remaining customers are likely to be sicker than current Obamacare buyers, a reality that will drive up the cost of insurance for everyone who buys it, and force more people out of the markets.The Urban Institute estimates that the change would cause 22.5 million people to lose their health insurance.What might replace it?Separate legislation may include some new form of subsidy to help people afford insurance.Plans from House Speaker Paul Ryan and the budget committee chairman, Tom Price, President-elect Donald Trump's pick to lead the Department of Health and Human Services, would offer a flat tax credit to help buy insurance that varies by age.A proposal from the House Republican Study Committee would give all Americans a standard tax deduction to buy insurance.Expanding MedicaidThe health law provided federal funds for states to offer Medicaid coverage to anyone earning less than about $16,000 for a single person or $33,000 for a family of four. Not every state chose to expand, but most did.What would happen?The Republican plan is expected to eliminate federal funding for the expansion. An estimated 12.9 million people would lose Medicaid coverage, according to the Urban Institute's projections.What might replace it?Republican leaders have discussed reforming the remaining Medicaid program to give states more autonomy and to reduce future federal investment.Consumer protectionsOne of the law's signature features prevents insurance companies from denying coverage or charging a higher price to someone with a pre-existing health problem. The law included other protections for all health plans: a ban on setting a lifetime limit on how much an insurer has to pay to cover someone; a requirement that insurers offer a minimum package of benefits; a guarantee that preventive health services be covered without a copayment; a cap on insurance company profits; and limits on how much more insurers can charge older people than younger people. The law also required insurance plans to allow adult children to stay on their parents' policies until age 26.What would happen?These rules can't be changed using the special budget process, so they would stay in place for now. But eliminating some of the other provisions, like the subsidies, and leaving the insurance rules could create turmoil in the insurance markets because sick customers would have a much stronger incentive to stay covered when premiums rise.What might replace it?Trump has said that he'd like to keep the law's policies on pre-existing conditions and family coverage for young adults, but Senate Republicans recently voted against nonbinding resolutions to preserve those measures, suggesting they may be less committed.Some of the other provisions would probably be on the table if there were new legislation. Republicans in Congress would probably eliminate rules that require a minimum package of benefits for all insurance plans and allow states to determine what insurers would have to include.Trump has said he'd like to encourage the sale of insurance across state lines, a policy likely to make coverage more skimpy but less expensive for many customers. Republicans would also like to expand tax incentives for people to save money for health expenses.Many of the Republican proposals would also establish high-risk pools, which would provide subsidized insurance options for people with chronic health problems who wouldn't be able to buy insurance without rules forcing insurers to sell them coverage.Coverage mandatesTo ensure that enough healthy people entered insurance markets, the law included mandates to encourage broader coverage. Large employers that failed to offer affordable coverage, or individuals who failed to obtain insurance, could be charged a tax penalty.What would happen?The bill is expected to eliminate the mandates. Some experts think that eliminating the individual mandate, in particular, could destabilize insurance markets by reducing incentives for healthy people to buy coverage. The mandate had less of an impact on the employers, which had already been offering coverage.What might replace it?Some Republican plans would allow insurers to charge much higher rates to customers who allow their coverage to lapse than to those who renew their policies every year. Such a system might provide a different financial incentive for healthy people to stay insured.Medicare reformsThe law cut the annual pay raises Medicare gives hospitals and reduced the fees Medicare pays private insurance companies. It created new incentives for hospitals and doctors to improve quality. It also set up a special office to run experiments in how Medicare pays doctors and hospitals for health care services. Those experiments are widespread and have begun changing the way medicine is practiced in some places.What would happen?The new legislation is expected to leave these changes alone, even though many have come under criticism by Republicans in Congress over the years, including from Price, an orthopedic surgeon. Many of the experiments could be reshaped or eliminated through regulation or through a future budget process.What might replace it?Republicans in Congress have long talked about even more ambitious changes to Medicare, intended to move more beneficiaries into private insurance coverage. Trump has said that he does not want to make major changes to Medicare, so it is unclear if such a proposal would move forward.Margot Sanger-Katz, The New York Times  Continue reading...