When the U.S. House of Representatives finally made good on its promise to repeal the Affordable Care Act Thursday, Josh Schiffer felt a pit in his stomach.
Schiffer’s five-year-old daughter has a congenital heart defect, the kind of pre-existing condition that insurance companies used to refuse to cover or charge with outlandish premium prices — before the Obamacare law. Would she be able to get health insurance under the new GOP health plan?
“This is something that is already terrifying and scary and strikes at the heart of anyone with kids,” he said.
The Republican bill that passed the House is almost certain to undergo a makeover in the Senate. Still, it marks an opening gambit in a new conservative political landscape, a gambit with a huge real-world impact on families, their taxes and budgets. Opinions on the plan in Georgia, so far, are mixed, and often quite strong. Some view the changes as pushing them to a the edge of a medical or financial precipice, while others believe they could be freed of bills they don’t want and mandates they don’t need.
In Buckhead, Greg Williams falls into the second category.
He wants less coverage. Ever since Obamacare outlawed his bare-bones health insurance plan as too risky, he’s been paying at least $120 more a month for extra coverage that he doesn’t want.
“It’s a better overall plan, but I would prefer to have the choice of going back to the catastrophic plan,” he said.
Politically, the bill that passed the House Thursday was a big win for Republicans and President Donald Trump who made repealing and replacing Obamacare a core campaign promise. Republicans say the legislation represents a better alternative to Obamacare and will help inject more competition into the marketplace, helping lower skyrocketing health care premiums and giving people more choices.
“We will get it done. We will have great, great health care for everyone in our nation,” Trump told reporters after the vote Thursday.
But as policy, the bill is a long way from becoming law, and it’s not even clear its own advocates like it.
The American Health Care Act, as the GOP bill is called, is the same that made headlines and failed in March. But with a couple of significant additions.
To win over hard-right conservatives, Republican leaders added an amendment to the bill. It worked, gaining their support, but has raised new alarm bells for health care providers, consumer groups and others.
The original GOP bill was estimated to make insurance difficult enough to obtain that 24 million Americans could go without coverage after its passage, according to the nonpartisan Congressional Budget Office, through changes in Medicaid and other provisions. The newly tweaked bill would do even more.
Credit: Shannon McCaffrey
Credit: Shannon McCaffrey
It would also allow states to get a “waiver” to opt out of two key Obamacare policies. First, insurers would no longer be forced to offer certain “essential” health benefits, such as maternity care and mental health treatment. Second, it would let insurers charge people with cancer or other pre-existing conditions higher premiums.
Critics of the bill say such a move would strip millions of Americans of the health coverage they depend on to survive.
While insurers wouldn’t be allowed to outright deny coverage to those with poor health histories like they could before Obamacare, premiums could rise so high that insurance could effectively be out of reach.
Suddenly a $200 monthly premium could be $2,000, said Karen Pollitz, a health care policy expert with the nonprofit Kaiser Family Foundation. “These will be premiums set to make you go away,” she said.
There are no CBO estimates of how the amended bill could impact people because House leaders rushed it through too fast for that. But other groups have taken a crack at predicting what lifting the protection for pre-existing conditions would do.
If Georgia chose to get a waiver, more than 70,000 people with poor health histories who have to buy individual insurance could be at risk, according to an analysis by Avalere Health, a Washington D.C.-based health care consulting firm.
The firm estimates that nationwide some 2.2 million Americans could lose coverage because of the provision.
“If any large states receive a waiver, many chronically ill individuals could be left without access to insurance,” said Caroline Pearson, senior vice president at Avalere.
About 1.8 million Georgians under the age of 65 have a pre-existing condition, a Kaiser analysis shows.
And more of them would be at risk of being affected by the bill than you might think, if you look at their insurance situation over time.
Most Georgians no longer enjoy the sterling protections of employer-based health insurance. In Georgia, 46 percent — or roughly 4.6 million people — had employer-based insurance as of 2015, according to Kaiser.
And like it or not, within any three-year span, roughly one in four Americans ends up in the individual health insurance market, estimated Pollitz.
It is often unexpected: They get laid off; turn 26 and can no longer be on their parents’ insurance; or lose coverage through a spouse when they get divorced.
Before Obamacare, if you had to buy individual insurance and weren’t in perfect health, you were going to have trouble buying coverage, she said.
People with devastating illnesses, such as HIV, would be outright rejected. Those whom insurers did agree to cover faced exorbitant premiums or couldn’t get coverage for their pre-existing conditions.
‘We’re all on the same team’
Roselynn Pearson is watching events in Washington with dismay.
“The patches that are being written by the lawmakers, there’s just such a scramble,” she said. “I mean, come on, give it time. We’re all on the same team here.”
Pearson speaks from experience. In 2011, she was a self-employed marketing consultant with a pre-existing condition, a congenital heart defect. Insurance plans wouldn’t cover anything to do with the heart defect, but the premium costs and deductibles for her remaining coverage skyrocketed anyway. It got to the point where she couldn’t afford them along with her heart health expenses, which were all out of pocket. So she dropped insurance.
And then learned she had uterine cancer.
She counts herself lucky that Obamacare had just gone into effect; she got her treatment covered. That’s the nightmare for insurance companies, but the care it paid for saved her life. Today, she has no evidence of cancer.
Credit: Shannon McCaffrey
Credit: Shannon McCaffrey
She’s now on Medicare, but she fears that someone like her will be in danger if lawmakers don’t step back and take a breath.
“It’s a gut smacking, surreal kind of experience.” Without the Obamacare coverage, Pearson said, “I don’t think I would have been insurable.”
Congress needs to take some care with the issue, and this bill is not the answer, she said: “For me it’s going back.”
Fix or Faux Fix?
What pushed the bill over the top for the winning vote was a fix House leaders offered aimed at dealing with the pre-existing conditions problem. They added a pot of money, $8 billion over five years, that states could use to create what are called high-risk pools.
These pools offer coverage to people with expensive illnesses who can’t get insurance on the private market. But they are often extremely costly for states to operate. And in cases where they’ve been tried, the results were very mixed.
As to the $8 billion, experts say it’s not nearly enough to do the job.
That amount, in addition to another $15 billion in the the bill to help people with pre-existing conditions, would only cover an estimated 110,000 individuals, the Avalere analysis shows.
The GOP bill also includes $100 billion over nine years for a Patient and State Stability Fund. That money can be used for any number of things, such as lowering out-of-pocket costs for low-income Americans or payments to safety net providers who care for large numbers of uninsured patients.
Even if all of the dollars allocated in the bill were used to fund high-risk pools, it would still only be enough to cover about 600,000 people, according to Avalere. That’s far less than the estimated 2.2 million people who would need help.
On to the Senate
Many of the same debates that slowed consideration of the health care bill in the House are expected to pop up in the more moderate Senate.
Majority Leader Mitch McConnell has a delicate needle to thread. Assuming that Vice President Mike Pence would offer a tie-breaking vote, he has only two votes to spare in his 52-member Republican conference.
His battle is tougher than House Speaker Paul Ryan’s. He’s got a smaller majority, yet his caucus contains the same divide in philosophies that made passage in the House such a slog. He must bridge ideological gaps between arch conservatives, such as Ted Cruz of Texas who want to remove the government from the health care equation as much as possible, and centrists from Republican states that expanded Medicaid, such as Lisa Murkowski of Alaska, who are worried about constituents losing insurance coverage.
It’s widely expected that if Senate Republicans are able to emerge with a compromise bill of their own that it would look very different from the House’s. And that prospect could endanger its chances back in the House down the road.
Republican leaders have yet to lay out a timeline for the Senate with some saying that they won’t restrict themselves to artificial deadlines. Consideration could take months.
In the meantime, leaders have convened a working group of Republican senators spanning the party’s ideological spectrum to try and find overlap.
Georgia’s two Republican senators, David Perdue and Johnny Isakson, have refrained from detailing their thoughts on the House bill, although both have sounded positive notes about it in the past. The two are more inclined to vote for the final product than other more politically vulnerable Republicans.
“Today is a good day because President Trump and the House of Representatives made real progress in the effort to improve our health care system and make it better for everyone going forward,” Perdue said through a spokeswoman on Thursday. “Obamacare is collapsing under its own weight.”
Both Perdue and Isakson have indicated that a major priority for them will be making sure that states like Georgia that did not expand Medicaid under Obamacare aren’t disadvantaged under the Senate Republican proposal.
After the first House health care plan collapse in March, both Georgia senators preached the need to work with Democrats on health care, but it’s unclear if they’ll stick to that position now that left-leaning senators have indicated they don’t plan on helping Republicans repeal the Affordable Care Act.
‘There’s a balance’
Georgians like Chris Campbell think the two sides should work together.
Campbell is a 34-year-old insurance brokerage owner who is glad the Republicans are moving forward on Obamacare repeal. He doesn’t like being forced to pay for mandatory levels of coverage, and he doesn’t like it being so expensive for him that he has to choose a stratospheric deductible — $10,000, he says.
He doesn’t want people to lose coverage for pre-existing conditions. But he heard about the $8 billion to go toward that issue. “That did make a difference,” he said.
He simply doesn’t believe that the CBO’s and others’ estimates on coverage losses will bear out; he thinks the opposite will happen if restrictions on insurance companies are loosened.
“I do believe that the free market would actually create a better product and lower price, as basic market principles tell us,” he said.
Even with his stance, Campbell thinks both parties should ditch their stereotypes and extreme stances and work together.
“There’s a balance. Companies have to make money,” he said. “But we want to make sure that things happen in a way that we will be compassionate too.”
BY THE NUMBERS:
Georgia and the GOP health care bill
1.8 million: Georgians under the age of 65 with pre-existing conditions.
72,000: Estimated number of people with pre-existing conditions whose insurance coverage could be at risk if the GOP plan were to become law.
46: Percentage of Georgians who had employer-based insurance in 2015.
500,000: Georgians with Obamacare coverage. Many could lose out on hundreds or even thousands of dollars in tax credits under the GOP plan.
2 million: Georgians on Medicaid, including low-income kids, pregnant women, the elderly and disabled. The GOP bill could drastically cut federal spending on Medicaid.