In March, we posted a blog on what the American Health Care Act (AHCA) would mean for people with disabilities comparing it with the eight principles we outlined in the statement we put out after the November 2016 election (“Preserve the Protections Provided by the Affordable Care Act“). Since the AHCA was introduced in March, several amendments have been proposed which would affect people with disabilities. Here is an updated analysis of how the AHCA would affect people with disabilities through our eight principles:
- Prohibition against Denial of Coverage for Pre-Existing Conditions: In theory, the AHCA maintains the ACA protection that insurance companies cannot deny coverage due to a pre-existing conditions. However, other changes could affect this protection (see #3 & 4 below).
- Guaranteed Renewability of Coverage: The AHCA maintains the ACA protection that insurance companies must renew anyone’s coverage.
- Prohibition against Individual Underwriting: With the MacArthur amendment, the AHCA would allow states to seek a waiver from the ACA requirement that insurance companies set rates based on community ratings and prohibit them from setting premiums based on disability or health conditions. So in states that seek the waiver, people with disabilities could have their premiums set at a much higher amount, effectively pricing them out of the market. States requesting these waivers would have to address high risk individuals through one of a few options, including high-risk pools or reinsurance programs.
- Essential Health Benefits Required in Every Qualified Health Plan: The AHCA already eliminated the essential health benefits (EHBs) for the Medicaid program. However, with the MacArthur amendment, the AHCA would allow states to seek a waiver from the ACA requirement that insurance companies be required to offer plans that cover ten EHBs. These EHBs cover a variety of things, including prescription medication, mental health treatment, durable medical equipment or other medical devices, or rehabilitation and/or habilitation benefit, among others. All of these benefits are of significant importance to people with disabilities and allowing states to seek a waiver from requiring insurance companies to provide the EHBs puts people with disabilities at risk that they will not be able to have affordable, comprehensive coverage which will meet their needs. Without the EHBs, insurance companies will be allowed to determine what is covered and effectively deny coverage for pre-existing conditions by not providing coverage for the services that those pre-existing conditions require.
- Prohibition against Lifetime Monetary Caps: The AHCA maintains the ACA protection which prohibits insurance companies from placing lifetime or annual monetary caps on the amount they will reimburse for care. However, it should be noted that the lifetime and annual monetary caps are directly related to the essential health benefits, meaning that if states change the EHBs through a waiver, this could have a direct impact on the prohibition against monetary caps as insurance companies could place monetary caps on those benefits that a state no longer considers essential.
- Prohibition against Discrimination in Health Programs: The AHCA keeps §1557 which prohibits discrimination in any health programs on the basis of race, nationality, disability, age, or sex.
- Extension of Mental Health Parity to the Individual and Small Group Market: The AHCA does not change the mental health parity law so it will continue to apply equally to the employer and large group markets as well as the individual and small group markets.
- Medicaid Expansion: Under the AHCA, the Medicaid expansion would remain in effect through 2019, but beginning in 2020 the Medicaid program as a whole would transfer to a per capita cap. The per capita cap would mean that the federal government would pay a set amount per enrollee to the states. We believe this would significantly undermine the Medicaid program and would most likely lead to reduced access to care for people with disabilities on Medicaid. AAHD is a member of the Consortium for Citizens with Disabilities (CCD) and CCD has put out a statement indicating how detrimental both block grants and per capita caps could be on people with disabilities. That CCD statement can be downloaded here.
In our prior blog post, we pointed out some of the other problematic provisions of the AHCA especially as it relates to the premium tax credits. As a result of the MacArthur amendment, we feel that the AHCA has actually taken a step back in preserving the protections the ACA provided for people with disabilities. Therefore, the American Association on Health and Disability (the lead partner for the NDNRC) continues to oppose the AHCA and urges Congress to reject it.
The more recent discussion of including a provision which would provide more money for the high-risk pools would not even come close to addressing the issues that would arise from eliminating these important protections for people with disabilities and/or pre-existing conditions. In our original ACA statement, we addressed the idea of-risk pools and point out that they have already been attempted and failed. For more information on high-risk pools, check out this list of resources:
- American Medical Association: AMA Warns Proposed Changes to AHCA Do Not Remedy Bill’s Shortcomings (May 2017)
- Avalere: Proposed High Risk Pool Funding Likely Insufficient to Cover Insurance Needs for Individuals with Pre-Existing Conditions (May 2017)
- National Health Council: High-Risk Pools (May 2017)
- Center on Budget and Policy Priorities: $8 Billion Comes Nowhere Close to Meeting Republican Commitments to People with Pre-Existing Conditions (May 2017)
- Families USA: Reported Upton-Long Amendment Does Virtually Nothing to Address Coverage for People With Pre-Existing Conditions (May 2017)
- Commonwealth Fund: High-Risk Pools for People with Preexisting Conditions: A Refresher Course (March 2017)
- Commonwealth Fund: Essential Facts About Health Reform Alternatives: High-Risk Pools (March 2017)
- Kaiser Family Foundation: High-Risk Pools For Uninsurable Individuals (February 2017)
- Commonwealth Fund: Why High-Risk Pools (Still) Won’t Work (February 2015)
- Commonwealth Fund: Why a National High-Risk Insurance Pool Is Not a Workable Alternative to the Marketplace (December 2014)
- Commonwealth Fund: Early Implementation of the Pre-Existing Condition Insurance Plans: Providing an Interim Safety Net for the Uninsurable (June 2011)