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Tag Archives: ACA Repeal
Pre-existing Conditions and Medical Underwriting in the Individual Insurance Market Prior to the ACA
Pre-existing Conditions and Medical Underwriting in the Individual Insurance Market Prior to the ACA
Brief
Before private insurance market rules in the Affordable Care Act (ACA) took effect in 2014, health insurance sold in the individual market in most states was medically underwritten.1 That means insurers evaluated the health status, health history, and other risk factors of applicants to determine whether and under what terms to issue coverage. To what extent people with pre-existing health conditions are protected is likely to be a central issue in the debate over repealing and replacing the ACA.
This brief reviews medical underwriting practices by private insurers in the individual health insurance market prior to 2014, and estimates how many American adults could face difficulty obtaining private individual market insurance if the ACA were repealed or amended and such practices resumed. We examine data from two large government surveys: The National Health Interview Survey (NHIS) and the Behavioral Risk Factor Surveillance System (BRFSS), both of which can be used to estimate rates of various health conditions (NHIS at the national level and BRFSS at the state level). We consulted field underwriting manuals used in the individual market prior to passage of the ACA as a reference for commonly declinable conditions.
Discussion
The Affordable Care Act guarantees access to health insurance in the individual market and ends other underwriting practices that left many people with pre-existing conditions uninsured or with limited coverage before the law. As discussions get underway to repeal and replace the ACA, this analysis quantifies the number of adults who would be at risk of being denied if they were to seek coverage in the individual market under pre-ACA rules. What types of protections are preserved for people with pre-existing conditions will be a key element in the debate over repealing and replacing the ACA.
We estimate that at least 52 million non-elderly adult Americans (27% of those under the age of 65) have a health condition that would leave them uninsurable under medical underwriting practices used in the vast majority of state individual markets prior to the ACA. Results vary from state-to-state, with rates ranging around 22 – 23% in some Northern and Western states to 33% or more in some southern states. Our estimates are conservative and do not account for a number of conditions that were often declinable (but for which data are not available), nor do our estimates account for declinable medications, declinable occupations, and conditions that could lead to other adverse underwriting practices (such as higher premiums or exclusions).
While most people with pre-existing conditions have employer or public coverage at any given time, many people seek individual market coverage at some point in their lives, such as when they are between jobs, retired, or self-employed.
There is bipartisan desire to protect people with pre-existing conditions, but the details of replacement plans have yet to be ironed out, and those details will shape how accessible insurance is for people when they have health conditions.
California’s Projected Economic Losses under ACA Repeal
Click to access Californias-Projected-Economic-Losses-under-ACA-Repeal.pdf
If Congress follows through on President-elect Trump’s campaign promise to repeal the Affordable Care Act (ACA), 3.7 million Californians enrolled in the Medi-Cal expansion would lose that coverage,1 and another 1.2 million individuals enrolled through California’s health benefit exchange, Covered California, would lose federal subsidies to make private health insurance more affordable.2 These two ACA provisions are the largest drivers of the historic reduction in the state’s uninsured rate from 17.2% in 2013 to 8.6% in 2015.
Not only would repeal of the ACA reverse much of these coverage gains, but California would lose approximately $20.5 billion in annual federal funding for the Medi-Cal expansion and Covered California subsidies. The economic losses associated with these lost federal dollars would be partially offset by limited economic gains from other provisions that may be included as part of the repeal of the ACA, which could yield $6.3 billion in tax cuts to California insurers and high-income households and nearly $1.3 billion in eliminated penalties for uninsured individuals and employers not offering affordable coverage.
In this brief, we estimate the effects on employment, gross domestic product (GDP), and state and local tax revenue in California with the elimination of the major health insurance expansions, reduction in taxes, and removal of penalties under a partial repeal of the ACA. A summary of these estimates is shown in Exhibit 1. We also estimate losses for select medium and large counties that would be especially harmed economically by ACA repeal because of their high share of population (more than 10%) enrolled in the Medi-Cal expansion: Fresno, Kern, Los Angeles, San Bernardino, San Joaquin, Stanislaus, and Tulare Counties.
CONCLUSION
The ACA not only significantly expanded access to health insurance in California, but it also provided economic stimulus at a time when the state was still recovering from the Great Recession. As California is one of the states that made the greatest gains in health coverage under the ACA,16 it is also one of the states with the most to lose economically if key components of the ACA are repealed. The partial repeal of the ACA would not only lead to a substantial decline in health coverage in California, but it would also lead to significant economic losses, including more than 209,000 lost jobs, $20 billion in lost GDP, and $1.5 billion in lost state and local tax revenue. Some medium and large California counties’ economies – Fresno, Kern, San Bernardino, San Joaquin, Stanislaus, and Tulare – would be especially harmed due to their residents’ high level of reliance on the Medi-Cal expansion and above-average unemployment rates.
ACA Repeal in California: Who Stands to Lose?
Click to access ACA-Repeal-in-California.pdf
California has a lot to lose if the Affordable Care Act (ACA) is repealed. The state made significant investments in implementing the law successfully, and under the ACA cut the number of uninsured residents in half, from 6.5 million in 2013 to 3.3 million in 2015—the largest decline in the uninsured rate of any state.1 The two major reasons for this drop in uninsurance were the expansion of Medicaid and the provision of financial assistance for purchasing coverage through the state health insurance marketplace, Covered California. As a result of these policies, California experienced a significant reduction in health coverage disparities: the biggest drops in the uninsurance rate were among those least likely to have coverage before the ACA, namely those with the lowest income, young adults, part-time workers, and Latinos.2 Repealing the ACA threatens not only to leave millions without health insurance, but also to undo the progress California has made in reducing inequality of health insurance access. This brief focuses on Californians enrolled in expanded Medi-Cal (the state’s Medicaid program) and those who receive subsidized coverage through Covered California, the two groups most immediately affected if the ACA is repealed. However, many more Californians could see diminished health coverage under various Congressional Republicans’ proposals to repeal and replace the ACA.
HSAs: ‘Tax-Break Trifecta’ Or Insurance Gimmick Benefiting The Wealthy?
HSAs: ‘Tax-Break Trifecta’ Or Insurance Gimmick Benefiting The Wealthy?
They are just three little words — “health savings accounts” — but they are generating a lot of buzz as Republicans contemplate plans to repeal and replace the Affordable Care Act.
Expanding the use of such accounts, based on a long-held conservative view that consumers should be more responsible for their health care spending, is part of almost every GOP replacement plan under consideration on Capitol Hill.
Here’s the theory behind HSAs: Making consumers bear a bigger up-front share of medical care — while making it easier to save money tax-free for those costs — will result in more judicious use of the health system that could ultimately slow rising costs.
While the details of the current proposals differ, they all generally seek to allow larger tax-free contributions to the accounts and greater flexibility on the types of medical services for which those funds can be used. Some include tax credit subsidies to help fund the accounts.
Supporters say premiums for the insurance linked to an HSA are lower, and they like HSAs’ trifecta of tax savings — no taxes on contributions, the growth of the funds in the account or on their withdrawal if spent on medical care. But skeptics note the tax break benefits wealthy people more than those with lower incomes.
Still, expect to hear a lot more about HSAs in the coming months. Here’s what you need to know:
Hospital Impact: No consensus in sight for the Republican ACA replacement
Two major proposals emerged last week to replace the Affordable Care Act that differ significantly in both content and potential impact.
Clearly, both of these proposals represent initial offerings that will be modified or even replaced by others as Republican lawmakers tackle the difficult task of fixing a flawed and controversial law. The ACA offers important protections yet requires modification into a sustainable model that supports both insurance providers and those most in need of healthcare services.
Clearly the work on replacing the ACA has just begun.
Obamacare is not ‘toast.’
https://www.healthinsurance.org/blog/2017/01/20/obamacare-is-not-toast/
Republicans have the votes – and pressure from their base – to demolish many of the ACA’s gains. Here’s why they probably won’t.
Hospital Impact: Why preserving value-based care is vital for my health system
There will continue to be a lot of talk about the repeal of the Affordable Care Act over the next weeks and months. From my perspective, I am hopeful that the Trump administration and Congress will keep their focus on the payment aspects of the ACA to ensure affordability for those in need.
My health system has been delivering care under a value-based care delivery model for the last six years, and I don’t want to see that care model go away under the repeal of the law. Quite frankly, this approach to care delivery should be the model for the entire nation.
We have been making a difference in the lives of so many through an approach that provides comprehensive, interdependent care to the sickest of the sick. We started with those patients with multiple comorbidities such as heart disease, diabetes, hypertension and COPD. Through our on-campus Center for Clinical Resources, we can now address their care needs simultaneously through the efforts of physicians, nurse practitioners, nurses, pharmacists, respiratory therapists, dieticians, navigators, community health workers and care coordinators.
The model has been so successful that we are now taking the concept out to the community. We identified “hot spots” throughout our service area where patients with the highest utilization of our health system are located. We applied our high-utilizer determination criteria of three or more bedded visits within 12 months, or six or more emergency department visits with a bedded visit and readmission within 12 months, to determine these patients and their locations. We are now delivering care in homeless shelters, with senior housing, low-income housing, senior centers and churches to follow.
Our goal is to disrupt these high utilizers’ cycle of use by providing services before an ED visit becomes necessary; assisting them to address their social determinants; intervening on any behavioral health issues; introducing those in need to a community health worker who can address any ongoing social needs such as transportation to appointments; and setting them up with a primary care provider for their care going forward.
Two years ago, we introduced our first community garden, and last year our gardens grew to five additional gardens serving those in need. We anticipate the same growth with this model of taking care to the community.
If the ACA is repealed and impacts our care delivery model, programs such as these will go away, leaving the most vulnerable once again in need of the most expensive care rather than enabling us to use the Triple Aim-focused approach to their care.
GOP talk shifts from replacing ObamaCare to repairing it
Key Republican lawmakers are shifting their goal on ObamaCare from repealing and replacing the law to the more modest goal of repairing it.
It’s a striking change in rhetoric that speaks to the complexities Republicans face in getting rid of the Affordable Care Act. Many of the law’s provisions are popular, and some parts of the law that the GOP does want to repeal could have negative repercussions on the parts seen as working.
“I’m trying to be accurate on this that there are some of these provisions in the law that probably will stay, or we may modify them, but we’re going to fix things, we’re going to repair things,” House Energy and Commerce Committee Chairman Greg Walden (R-Ore.), a key player on healthcare, told reporters Tuesday.
“There are things we can build on and repair, there are things we can completely repeal,” he said.
Senate Health Committee Chairman Lamar Alexander (R-Tenn.) is sounding a similar note. He notes that Republicans plan to use special budget rules known as reconciliation to prevent Democrats from filibustering a vote to repeal ObamaCare. The use of those rules won’t allow all of ObamaCare to be repealed.
“I think it is more accurate to say repair ObamaCare because, for example, in the reconciliation procedure that we have in the Senate, we can’t repeal all of ObamaCare,” Alexander said. “ObamaCare wasn’t passed by reconciliation, it can’t be repealed by reconciliation. So we can repair the individual market, which is a good place to start.”
Not everyone is on board with the new rhetoric.
Some Republicans say their party should be focused on repealing the law and replacing it, not repairing it.
“I’m hearing a lot of members say that they want ObamaCare-lite,” said Rep. Raúl Labrador (R-Idaho). “That’s not what we promised the American people.”
U.S. Health Care Reform Will Require Politicians to Change Their Attitude
https://hbr.org/2017/02/u-s-health-care-reform-will-require-politicians-to-change-their-attitude
It is no secret that replacing the Affordable Care Act, popularly known as Obamacare or the ACA, is high on the agenda of the incoming Republican administration and Congress. Speaker Paul Ryan has said that the law has “failed.” In the campaign debates, Donald Trump said it was “destroying our country.” But even as the new administration has issued its initial executive orders, Republicans have yet to offer a true alternative plan, and the timing on replacement is still hazy.
Given that one party controls both the executive and legislative branches of government, one might be tempted to think that “renegotiate” may be the wrong word — that “fiat” may more appropriate. Not so fast. There are Republican governors who oppose the rollback of Medicaid expansion. Even within Congress there are differences over whether a repeal should take effect immediately or over time. Despite the demonization of the ACA on the campaign trail, there are elements of the law that are quite popular across the political spectrum. While the president has stated on the record that he wants health care for everyone, his nominee for secretary of health and human services refused to back that promise in confirmation hearings.
The policy and politics promise to be nettlesome at best, and many experts are weighing in. At the Program on Health Care Negotiation and Conflict Resolution, at the Harvard T.H. Chan School of Public Health, we look most closely at the leadership and negotiation issues, each of which offers opportunities as well as pitfalls that can be seen clearly even now.
Given the number of stakeholders and the diversity (and divergence) of their interests and points of leverage, “renegotiating” is exactly the right word. And there are few negotiations as complex as reforming the U.S. health care system. Certain changes can be forced into the system from on high, but the essential goodwill, commitment, and voter loyalty that political will is derived from cannot be commanded.
The promise of much better care at greatly reduced costs for citizens is simply a fantasy unless Congress is willing to increase subsidies for coverage. The budget hawks on Capitol Hill are not likely to go along with that. Or they could regulate prices, but that is also anathema to conservatives. Physicians and hospitals will come to the table wanting more now that they better understand the impact of the various components of the ACA. Insurers will remember that Congress funded just 12.6% of their claims under the “risk corridors” of the ACA and will want greater certainty regarding the risks they are undertaking. The public’s expectations are that the parts of the law they like will remain — including the expense-heavy coverage for preexisting conditions and elimination of lifetime benefit caps — while those they dislike, such as the employer and individual mandates that help mitigate risk and lower costs, will go away.
HENRY KOTULA 