Today, Senate Republicans released their version of the American Health Care Act (AHCA), or as the Senate is calling it, the Better Care Reconciliation Act of 2017 (BCRA). The AHCA was passed in the House in May as a replacement plan for the Affordable Care Act (ACA). We previously posted about what the original and final versions of the AHCA meant for people with disabilities and the eight core principles in the ACA that we believe need to be preserved. Here is an analysis of those eight principles and the BCRA.
- Prohibition against Denial of Coverage for Pre-Existing Conditions: In theory, the BCRA 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 BCRA maintains the ACA protection that insurance companies must renew anyone’s coverage.
- Prohibition against Individual Underwriting: The BCRA does not follow the House’s AHCA as it does not allow states to seek a waiver which would allow an insurance company to surcharge individuals by health status if they experienced a gap in coverage. However, the BCRA does allow states to seek other waivers on essential health benefits (see #4), out-of-pocket limits and actuarial value requirements which could have an affect on how plans are underwritten and provide insurers with a back door way to medically underwrite people with disabilities.
- Essential Health Benefits Required in Every Qualified Health Plan: As with the House bill, the Senate’s BCRA eliminates the essential health benefits (EHBs) for the Medicaid program and allows 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 BCRA 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 EHBs, 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 BCRA 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 BCRA 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 BCRA, the Medicaid expansion would remain in effect through 2019, but beginning in 2020 the enhanced federal matching percentage would begin to phase out and the Medicaid program as a whole would transfer to a per capita cap (states would also be given the option to chose a block grant). The per capita cap would mean that the federal government would pay a set amount per enrollee to the states. Of note, one of the major differences between the BCRA and the AHCA is the growth rate for the per capita caps. In this way, the Senate bill is MUCH worse as the growth rate is lower meaning that the Medicaid cuts over time would be much more severe. We believe per capita caps, in general, significantly undermine the Medicaid program and will 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.
Under the BCRA, we believe that, just like the AHCA, it fails to preserve 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 both the AHCA and BCRA and urges Congress to reject them.