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With healthcare for millions at stake, Republicans unveil flawed, cost-cutting Affordable Care Act replacement

, by Emily Land

american flagRepublicans in Congress released a plan yesterday to repeal and replace the Affordable Care Act (ACA or “Obamacare”) that’s anticipated by policy experts to cover far fewer people than now covered by ACA. The draft bill, called the American Health Care Act, proposes changes to the ACA through the budget reconciliation process which would only require a simple majority of votes to pass.

Policy experts have combed through the bill’s language to decipher what would change under the new law, and what impact it might have on people that now rely on Medicaid and Affordable Care Act plans. Yesterday and today, many have taken to Twitter and other online forums to unleash their thoughts on the bill’s deficits.

Strong opposition to the draft bill

“The GOP health care proposal would be laughable if its consequences weren’t so devastating,” shared the health care consumer advocacy organization Families USA in a press release.

“If Trump wants a plan that covers everyone, he is not going to like this plan,” tweeted New York Times correspondent Margot Sanger-Katz yesterday. In an article published yesterday, Sanger-Katz explained that the proposed plan will likely cover fewer people than the current law does, and that the people who lose coverage will be those who are poorer.

“Poor, older adults would face the largest crunch: The magnitude of their tax credits shrinks, even as a separate provision in the bill allows insurers to charge older people substantially higher prices than are allowed under the Affordable Care Act,” wrote Sanger-Katz.

“With Medicaid reductions and smaller tax credits, there’s no way the House GOP bill covers as many people as the ACA, explained Larry Levitt, Senior VP of Kaiser Family Foundation yesterday on Twitter. “The GOP’s tax credits provide substantially less help than the ACA for low-income people, who were most likely to be uninsured pre-ACA.”

What changes under the new bill?

This bill makes big funding cuts and structural changes to the Medicaid program. It  reduces the amount of federal funding for states who operate a Medicaid expansion program and by fundamentally changing the structure of the program from being an entitlement program to instituting a per-capita cap on spending. This would mean that instead of states getting reimbursed by the federal government for a set percentage of all medical care provided under the program, states would get a set payment based on the number of enrollees. The amount that states would get for people signed up under the Medicaid expansion would be “substantially” reduced, by more than a third in some states, said Sanger-Katz.

“With capped and significantly reduced federal funding [to Medicaid], health care costs will shift dramatically to the states,” said Jane Perkins, legal director of the National Health Law Program in a press release issued today. “We can expect states to cut health services and limit eligibility. We are extremely concerned that these actions will hit children, older adults, pregnant women, communities of color, and people living with disabilities hard.”

The bill also repeals the individual insurance mandate, a central part of the ACA meant to keep younger and healthier people in insurance pools—in order to keep insurance affordable to people who are older or sick. The individual mandate is replaced with a 30% penalty imposed on people who go without insurance for two months or more.

The bill also repeals the employer mandate to provide affordable health insurance to employees, changes the way that subsidies are granted to people buying insurance plans, and defunds Planned Parenthood. (See this New York Times article for a summary of the proposed changes.)

The draft legislation is scheduled for “markup” this week and assuming it can get enough votes from the house, may proceed to a Senate vote sometime in the coming weeks. If the bill passes in the Senate, with at least 51 votes, it will go to the President for his signature.

What might the effects be on people living with HIV?

The ACA has significantly benefited people living with HIV since its implementation—by banning discrimination against people with pre-existing conditions and offering people affordable insurance plans from state-based exchanges and access to Medicaid in states where the program expanded. Kaiser Family Foundation estimates that the percentage of people living with HIV below the 100% federal poverty line without any insurance dropped from 22% in 2012 to 15% in 2014 after key parts of the ACA were implemented. And, that people living with HIV on Medicaid increased from 36% in 2012 to 42% in 2014.

“The ACA, and Medicaid expansion in particular, have been very important to covering the health care costs and needs of people living with HIV,” said Tim Wang, MPH and Sean Cahill, PhD from The Fenway Institute in an issue brief on the ACA.

There are a few components to the bill that will have a severe impact on people living with HIV, explained Ernest Hopkins, legislative affairs director at San Francisco AIDS Foundation.

“The first and most serious is the sunset of Medicaid Expansion in 2020,” said Hopkins. Since Medicaid is the largest payer of services for people living with HIV, changes to the program that limit its eligibility and reduce the ability of the program to address the true increases in cost do damage to clients and to the system.

Problems will also arise for people living with HIV, said Hopkins, if subsidies that help people pay premiums go away, if tax credits remain refundable, and the cost of insurance remains high. Generally, people who are older and sicker will see the highest cost increase under the proposed plan. “Most of our population will either return to Ryan White Care or be force to pay more out-of-pocket costs for insurance. If the AIDS Drug Assistance Program [ADAP] is still allowed to wrap around these high costs and cover them, without new money, we will have to reduce the number of clients served because each client will be more expensive to the system.”

Defunding Planned Parenthood, the largest provider of family planning in the U.S., could have devastating consequences on sexual health, reducing testing for sexually transmitted infections and HIV.

Finally, said Hopkins, the removal of patient protections and the federal essential benefit package means that people living with HIV will be at the mercy of their state insurance regulators. In turn, regulators will be under “tremendous pressure” to reduce the cost of care—which may ultimately cause them to reduce the requirements of what they define as “essential service delivery.” People living with HIV may find that things that are essential to their care—lab work, preferred medications, quality care—are not covered by revised insurance plans.

Further reading

Want to read more?

Healthy and Wealthy Benefit under the House Republicans’ Affordable Care Act Repeal Plan, by Families USA

Repealing Obamacare will have “devastating” consequences for millions—and many who are living with HIV, by BETA

Essential Elements of a Revised National Health Care Policy for LGBT People and People Living with HIV, by Tim Wang and Sean Cahill

Examining The House Republican ACA Repeal And Replace Legislation, by Timothy Jost



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