After much anticipation, on June 22, the Senate released its long-awaited bill to repeal or significantly alter much of the Affordable Care Act. Known as the Better Care Reconciliation Act, it has a number of components that are similar to the American Health Care Act the House of Representatives passed in May. Senate leadership have expressed a desire to vote on this bill during the coming week, before the Senate adjourns for its scheduled July 4 recess.
The Congressional Budget Office (CBO) is expected to release a cost estimate or “score” for the bill early this week, but as of the time of this alert at least five Republican senators have said they are going to vote against the bill in its current form. With all Senate Democrats expected to vote no, Republicans can lose no more than two votes if they want the bill to pass.
Let’s take a look at some of the key provisions of the legislation and how it may impact individuals living with psoriasis and psoriatic arthritis and their ability to access and use our health care system.
- Essential health benefits (EHBs): Both the House and Senate bills would establish a process for states to propose changes or waivers to what qualifies as an essential health benefit. The stated aim of this proposal is to reduce the regulatory and cost burdens on insurers, who would then be able to offer more affordable plans. But the impact could be a significant reduction of benefits, raising many questions as to the quality of such coverage. For individuals living with a chronic condition such as psoriasis or psoriatic arthritis, states may choose to allow insurance companies to offer plans that cover fewer treatments and services for individuals impacted by these diseases. It may also mean the return of lifetime or annual limits on coverage. The Senate bill would not allow states to permit insurers to charge persons more based on their health care status, thus maintaining protections for persons with pre-existing conditions. But if states allow massive changes to EHBs, this may well limit access to meaningful insurance coverage.
- Medicaid: Both the House and Senate bills propose a sweeping restructuring of Medicaid by changing it from a matching program to one that limits federal contributions through a system of per-capita caps or, if a state chooses, through block grants. The Senate bill exempts disabled children from the per-capita caps and, like the House bill, provides a more generous annual update factor to determine payments for the elderly and disabled. However, beginning in 2025, the Senate would institute a lower annual inflation growth rate than what is contained in the House bill. This means that the federal government would be contributing less to states to support Medicaid spending. With Congress reducing hundreds of billions of dollars in Medicaid payments to the states, states could cut enrollment, limit benefits, or reduce payment rates to providers and plans. As a result of these changes, individuals with psoriasis and psoriatic arthritis who rely on Medicaid may lose access to health care benefits.
- Charging older Americans more: Both the House and Senate bills would allow health insurers to charge older Americans significantly more for health care coverage than younger consumers. Currently, plans are limited in how much more they can charge (three times as much as younger subscribers). The House and Senate bills would both allow health insurance companies to charge older subscribers up to five times as much as younger enrollees.
- Coverage mandates: Both the House and Senate plans eliminate the mandate that large employers offer health care – something required by the ACA. The current individual coverage mandate imposed by the ACA would also be eliminated by the Senate. The House bill allows plans to impose a 30 percent (or more) premium surcharge to consumers who purchase a new plan after letting their previous coverage lapse — incentivizing healthy people to remain insured.
- Pre-existing conditions: As noted earlier, the Senate bill would not allow states to permit insurers to charge persons with pre-existing conditions more for health insurance. This is an improvement over the House bill and an important protection for individuals living with psoriasis and psoriatic arthritis. It would also ensure that at least some of the gains of the current law are not lost. However, if states are able to propose their own EHBs, this could make the retention of these protections almost irrelevant.
- Subsidies/premium support: Both the House and Senate bills reduce the premium supports (known as subsidies) offered to help individuals purchase health care. The Senate bill, though, would continue tax credits based on age, income and geography (while the House bill would only offer them based on age). These supports would not be as broad as they are today – individuals would need to be of lower income to qualify and would receive reduced assistance.
In sum, while the Senate bill released this week contains some improvements over the House bill, it nonetheless is expected to result in millions of Americans losing health care coverage. Of particular concern is how it will impact individuals with chronic conditions, older adults who are not yet eligible for Medicare, and those living on limited incomes.
Ultimately, the expectation is that this legislation as it now stands would lead to individuals with psoriasis and psoriatic arthritis paying more for less. This is unacceptable. While the current health care system has significant issues – challenges the NPF has been working to address through legislative and regulatory reform at both the state and federal level since passage of the ACA – this expansive rollback in coverage is not the right solution.
The opinions expressed by NPF Blog contributors are their own and do not reflect the opinions or positions of the National Psoriasis Foundation. The information posted on the NPF Blog is not intended as, and is not, a substitute for professional medical advice.
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