Illustration: Gabriella Turrisi / Axios
The massive House reconciliation bill was about more than Medicaid cuts and Trump tax cuts. It would also take steps to significantly roll back the Affordable Care Act.
Why it matters: Although much of the attention has been on the bill's Medicaid provisions, the final House draft called for an overhaul of ACA marketplaces that would result in coverage losses and savings for the government.
Driving the news: Many of the changes erect barriers to enrollment that supporters say are aimed at fighting fraud.
- Brian Blase, president of Paragon Health Institute and a health official in Trump's first administration, said Republicans are not trying to repeal the ACA but rather roll back Biden-era expansions "that have led to massive fraud and inefficiency."
- The CBO estimates the ACA marketplace-related provisions would lead to about 3 million more people becoming uninsured.
- Cynthia Cox, a vice president at KFF, said the changes "sound very technical," but that taken together, "the implications are that it will be much harder for people to sign up for ACA marketplace plans."
What's inside: The bill would end automatic reenrollment in ACA plans for people getting subsidies, instead requiring them to proactively reenroll and resubmit information on their incomes for verification.
- It would also prevent enrollees from provisionally receiving ACA subsidies in instances where extra eligibility checks are needed, which can take months.
- If people wound up making more income than they had estimated for a given year, the bill removes the cap on the amount of ACA subsidies they would have to repay to the government.
- Some legal immigrants would also be cut off from ACA subsidies, including people granted asylum and those in their five-year waiting period to be eligible for Medicaid.
What they're saying: In a letter to Congress, patient groups pointed to the various barriers as "unprecedented and onerous requirements to access health coverage" that would have "a devastating impact on people's ability to access and afford private insurance coverage."
- The letter was signed by groups including the American Cancer Society Cancer Action Network, American Diabetes Association and American Lung Association.
Between the lines: A last-minute addition to the bill would also fund cost-sharing reduction (CSR) payments to insurers.
- The effect of this change would actually be to reduce the subsidies that help people afford premiums, and save the government money, by reducing the benchmark silver premiums used to set the subsidy amounts.
- Democrats worry that if Congress also allows enhanced ACA subsidies to expire at the end of this year, the combined effect with the CSR change would be even higher premium increases for enrollees next year.
- Insurers are also worried that they are already planning their premium rates for next year, and that funding CSRs is throwing in a late curveball.
- "Disruption in the individual market could also result in much higher premiums," the trade group AHIP warned in a statement on the bill.
The big picture: Blase said changes like ending automatic reenrollment are needed to increase checks that ensure people are not claiming higher subsidies than they're entitled to.
- "I think what happened during the Biden years led to massive fraud and improper spending, and that needs to be rolled back," he said.
- Cox said another way to address fraud would be to target shady insurance brokers, rather than enrollees themselves. She estimated that marketplace enrollment could fall by roughly one third from all the changes together.
- "The justification for many of these provisions is to address fraud," she said. "The question is, how many people who are legitimately signed up are going to get lost in that process?"
