Jun 27, 2017

How the House and Senate bills would change "Obamacare"

Lazaro Gamio / Axios

Here is a rundown of the main elements of the Affordable Care Act, which ones would be wiped out and which could survive under the House and Senate bills, and what would change if the GOP legislation becomes law.

πŸ†˜ At risk: Pre-existing conditions, individual mandate, essential health benefits, employer mandate, taxes, Medicaid expansion, Medicaid funding, age rating.

⚠️ In play: Exchanges, subsidies, lifetime limits.

βœ… Safe: Young adult coverage, Medicare "doughnut hole," preventive care, Medicare payment cuts.

πŸ†˜ Pre-existing conditions
What the ACA does

People who get health insurance on their own can no longer be turned down for coverage because of pre-existing conditions. And insurers can't charge them higher premiums because of their health.

How it could change

House: Would still require insurers to cover people with pre-existing conditions. But states could get waivers to allow insurers to charge them higher premiums, as long as they have backup programs to cover sick people. The benefits could change, too. (There's an $8 billion fund to help with their costs.)

Senate: Would still require insurers to cover people with pre-existing conditions and charge them the same rates as everyone else. But the benefits could change. (See Essential Health Benefits.)

⚠️ Exchanges
What the ACA does

The law sets up exchanges, or marketplaces, to offer health plans and determine eligibility for tax credits. Twelve states, including the District of Columbia, run their own exchanges. The rest use the federal marketplace, HealthCare.gov.

How it could change

House bill: The House bill doesn't get rid of the marketplaces, but the Congressional Budget Office predicts that fewer insurers would participate, because they wouldn't have to offer health plans through the marketplaces for people to get subsidies.

Senate bill: The Senate bill doesn't get rid of the marketplaces, but a state could do so if it gets a "Section 1332" waiver.

βœ… Young adult coverage
What the ACA does

Young adults can stay on their parents' health insurance plans until age 26.

How it could change

House: This provision has become one of the most popular parts of Affordable Care Act, and the House bill keeps it.

Senate: Same.

πŸ†˜ Individual mandate
What the ACA does

Most Americans have to have health insurance, with tax penalties if they don't have coverage and don't qualify for an exemption. That's how the law tries to attract enough healthy people to help insurers pay the costs of sick people.

How it could change

House: The mandate would be repealed. The House bill would get rid of It retroactively, starting in 2016.

Senate: Same. Instead, the Senate bill would give people a different incentive to sign up: They'd have to wait six months for coverage if they have more than a 63-day lapse in health insurance.

⚠️ Subsidies
What the ACA does

Customers who don't have another source of health insurance get premium tax credits to help them buy coverage. The credits are available to people with incomes between 100 percent and 400 percent of the poverty line. There are also cost-sharing subsidies for low-income people.

How it could change

House: The tax credits and subsidies would be repealed. Instead, the House bill would create a refundable, age-based tax credit to help people buy health insurance plans. They'd start at $2,000 a year for people under age 30, with a maximum of $4,000 a year for people over age 60.

Senate: The tax credits would stay in place, but starting in 2020, they'd be narrowed to everyone up to 350 percent of the poverty line. They'd also give more help to young adults and less help to older people. The subsidies would be repealed in 2020.

βœ… Medicare "doughnut hole"
What the ACA does

Gradually closes the gap in Medicare Part D prescription drug coverage by 2020.

How it could change

House bill: Doesn't affect this provision.

Senate bill: Same.

πŸ†˜ Essential health benefits
What the ACA does

All health plans in the individual and small group markets have to cover 10 categories of benefits.

How it could change

House: States would be able to get waivers to set their own minimum benefits, starting in 2020. That could affect the benefits people with pre-existing conditions would get. And anything that's not considered an essential benefit can have annual and lifetime limits.

Senate: States could get waivers to set their own minimum benefits, effective immediately.

⚠️ Lifetime limits
What the ACA does

Health insurance companies can no longer limit how much they'll pay in benefits over a customer's lifetime.

How it could change

House: Technically, the House bill keeps this provision. But because it's tied to the ACA's essential health benefits, critics say the provision will become meaningless in states that waive the essential benefit rules.

Senate: Same.

πŸ†˜ Employer mandate
What the ACA does

Employers with the equivalent of 50 or more full-time workers have to pay penalties if they don't cover their workers, or if their health coverage doesn't meet affordability standards.

How it could change

House: The House bill would repeal the employer mandate retroactively, starting in 2016.

Senate: Same.

πŸ†˜ Taxes
What the ACA does

The law is funded in part through various taxes, including annual fees for health insurers, a 2.3 percent tax on the sale of medical devices, and a 3.8 percent tax on net investment income for wealthy people. It also creates a 40 percent "Cadillac tax" that will hit high-cost employer health insurance plans.

How it could change

House: The taxes would be repealed, except for the "Cadillac tax," which would be delayed until 2026.

Senate: Same.

πŸ†˜ Medicaid expansion
What the ACA does

States that expand their Medicaid programs to cover nearly all low-income Americans are given extra federal matching funds.

How it could change

House: The Medicaid expansion would end in 2020, though states would still be able to cover some new categories, like childless adults. States that already expanded Medicaid would still be able to enroll new people through 2019 and get the extra federal matching funds.

Senate: The Medicaid expansion would begin to phase out after 2020, with the extra funds being reduced over three years.

πŸ†˜ Medicaid funding
What the ACA does

The ACA didn't change the structure of Medicaid as an open-ended entitlement program. Everyone who meets the eligibility requirements has to be covered, and federal and state spending has to adjust.

How it could change

House: Starting in fiscal 2020, there would be per-capita caps on federal funding to the states. States could choose block grants as an alternative.

Senate: Starting in fiscal 2020, there would be per-capita caps on federal funding to the states. The growth rate would be the same as the House, but it would get tighter starting in fiscal 2025. States could choose block grants as an alternative.

πŸ†˜ Age rating
What the ACA does

Insurers in the individual and small group market can only charge premiums three times as high for older customers as for young adults.

How it could change

House: Insurers could charge older customers as much as five times more than young adults. Republicans say that's closer to the true variation in the cost of care.

Senate: Same.

βœ… Preventive care
What the ACA does

Requires most insurers to cover preventive services, like screenings and immunizations, without charging patients out-of-pocket payments like copayments or coinsurance.

How it could change

House: The bill leaves the requirement in place.

Senate: Same.

βœ… Medicare payment cuts
What the ACA does

Reduces Medicare payments to hospitals and other providers, producing roughly $800 billion in savings over 10 years to help pay for the law.

How it could change

House: The bill doesn't affect this provision.

Senate: Same.

Go deeper

Coronavirus dashboard

Illustration: AΓ―da Amer/Axios

  1. Global: Total confirmed cases as of 4 p.m. ET: 5,463,392 β€” Total deaths: 344,503 β€” Total recoveries β€” 2,195,325 β€” Map.
  2. U.S.: Total confirmed cases as of 4 p.m. ET: 1,653,904 β€” Total deaths: 97,948 β€” Total recoveries: 366,736 β€” Total tested: 14,163,915 β€” Map.
  3. World: Italy reports lowest number of new cases since February β€” Ireland reports no new coronavirus deaths on Monday for the first time since March 21 β€” WHO suspends trial of hydroxychloroquine over safety concerns.
  4. 2020: Trump threatens to move Republican convention from North CarolinaΒ β€”Β Joe Biden makes first public appearance in two months.
  5. Public health: Officials are urging Americans to wear masks over Memorial Day.
  6. Economy: New York stock exchange to reopen its floor on Tuesday β€” White House economic adviser Kevin Hassett says it's possible the unemployment rate could still be in double digits by November's election β€” Charities refocus their efforts to fill gaps left by government.
  7. What should I do? Hydroxychloroquine questions answered β€” Traveling, asthma, dishes, disinfectants and being contagious β€” Masks, lending books and self-isolating β€” Exercise, laundry, what counts as soap β€”Β Pets, moving and personal health β€” Answers about the virus from Axios experts β€” What to know about social distancing β€” How to minimize your risk.
  8. Other resources: CDC on how to avoid the virus, what to do if you get it, the right mask to wear.

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