Tagged Premiums

‘Coverage Gap’ For Poor May End, But Many Will Still Have Trouble Affording Plans

Having long decried the failings of the Affordable Care Act, Senate Republicans are purporting to fix one of its loopholes with their newly unveiled health plan. The so-called coverage gap left more than 2.5 million people living below the poverty line of $11,880 for an individual ineligible for Medicaid or financial assistance to buy insurance — even as higher earners got subsidy checks to buy theirs.

But experts say the fix, which looks fine on paper, is a mirage.

In fairness, the loophole was essentially created by Republicans and others when a Supreme Court decision meant that states were no longer required to expand Medicaid.

The Affordable Care Act offered help paying premiums to people earning between 100 to 400 percent of the poverty line, under the assumption that those under the poverty line would be covered by Medicaid.

So when 19 states decided not to expand Medicaid, millions of Americans were left in the coverage gap because they didn’t qualify for Medicaid and couldn’t afford private insurance.

As a remedy, the Senate bill would offer federal tax credits to help pay for insurance premiums for anyone earning between 0 and 350 percent of the poverty level (up to about $42,000 for an individual) starting in 2020. (Note that the upper ceiling is somewhat lower than that stipulated by the ACA.)

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But health law experts caution that this coverage gap fix for these very low earners would likely be largely undercut by two other changes in the bill.

First, the Senate’s plan would shift the calculation for subsidies. The ACA required that premium subsidies be linked to the price of a category of health insurance that was a kind of minimum standard for Obamacare and covered 70 percent of health costs on average — called a silver plan under Obamacare nomenclature. The Senate would instead tie the subsidy to the more bare-bones bronze plans, which cover on average only 60 percent of health costs.

Although low earners might qualify for subsidies to buy insurance, making coverage an option, they would likely have a hard time using the plans because bronze plans generally have higher deductibles and copayments.

In addition, the legislation in 2019 would discontinue a second ACA subsidy — the cost-sharing reductions offered to anyone earning less than 250 percent of the poverty level. These payments help cover out-of-pocket expenses. So even if marketplace customers got subsidies to help cover their premiums, their out-of-pocket costs could be too expensive and would likely keep them from using or buying coverage.

Gary Claxton, director of the Health Care Marketplace Project at the Kaiser Family Foundation, said expanding subsidies doesn’t mean the poor will find affordable coverage. “It will give people plans that are very difficult to use at their income levels,” he said, noting the coverage will likely have deductibles of over $6,000 a year. (Kaiser Health News is an editorially independent program of the foundation.)

Another factor that experts noted is the Senate plan would phase out the Medicaid expansion.

Theoretically, people affected by the end of that program could get federal subsidies to buy coverage under the Senate plan.

But experts say the benefits would likely not be as good. That’s because Medicaid typically provides services such as transportation to medical appointments and home health care, said Chiquita Brooks-LaSure, an insurance expert with the consulting firm Manatt Health.

Andy Slavitt, who oversaw the health law for the final years of the Obama administration, said that despite the fix, options for very-low-income people would be worse under the measure announced Thursday, eliminating Medicaid and moving people to bare-bones plans, with skimpier benefits.

“That’s the aim,” he said.

Categories: Insurance, Medicaid, Repeal And Replace Watch, The Health Law

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Winners And Losers: 40 Is Old In Senate GOP Health Plan’s Subsidy Structure

People getting subsidies to help buy health insurance would see at least three sharp changes — tied to both age and income — that could dramatically affect how much they pay for coverage if the Senate Republican health plan becomes law.

The Senate bill released Thursday would reduce the income thresholds that determine eligibility, change the amount people who receive help pay toward their insurance premiums and peg subsidies to less generous coverage.

About 85 percent of the nearly 10 million consumers who enrolled in coverage last year through federal and state marketplaces received tax credit subsidies and other types of financial assistance. Under the Senate plan, some could pay less in premium costs, but many, particularly older Americans, could see their share of payments go up. And let’s be clear — you’re old at about 40.

Incomes Eligible For Help Fall To 350 Percent Of Poverty

The Affordable Care Act provides tax credit subsidies on a sliding scale for people earning up to 400 percent of the federal poverty level — an amount that equals about $47,520 this year for individuals. Starting in 2020, the Senate bill would drop that to 350 percent, which is now an annual income of about $41,580. As a result, fewer people would qualify. To be sure, some enrollees who exceed that new income limit might lose only a small subsidy because of the way the current law is structured, but older enrollees could lose substantial amounts. The Center on Budget and Policy Priorities estimated Thursday that a 60-year-old earning just above the cutoff would lose at least $3,000 annually in subsidies.

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Age Matters

Tax credits are just one part of the picture. Under the ACA, subsidy-eligible enrollees must pay a percentage of their annual household income toward premiums, ranging from about 2 percent to just over 9.5 percent for those with higher incomes. Those amounts go up over time. The Senate bill would adjust those percentages based on age, keeping the lower limit at around 2 percent, but exceeding 16.2 percent at the highest income and age group. So if you are 39 or younger, you generally would pay smaller percentages of your income when compared with what you pay under the ACA, ranging from about 2 percent to 8.9 percent.

But once you hit 40, things change. Let’s say you earn $41,580 — 350 percent of poverty — you would pay more than 12.5 percent of your income, or $5,197, under the Senate plan. That compares with $4,029, or 9.69 percent currently under the ACA. At that same income level, percentages rise to 15.8 for those ages 50 to 59 and up to 16.2 percent of income for those 60 and up.

Aiming For Bronze: Subsidies Tied To Less Generous Coverage

The Senate would link the subsidies to plans with less generous coverage than the ACA. Subsidies under current law are pegged to a benchmark “silver” plan, which covers an average of about 70 percent of medical expenses. The Senate would peg the subsidy to the median price of a policy that covers about 58 percent of health costs, roughly equivalent to today’s “bronze” plans. Consumers pay the rest of the cost, usually through deductibles and copayments. This year, average deductibles for bronze plans were more than $6,000, while silver plans averaged $3,500, according to consumer website HealthPocket. People could still use subsidies to buy more generous plans, but the premiums would be higher.

Christopher Condeluci, who served as tax and benefit counsel to the Senate Finance Committee when the ACA was drafted, said the changes might prompt more people to buy insurance, noting that subsidies will be available to those who are under the federal poverty level, which they aren’t under current law. Younger people also might benefit by paying less toward coverage, helping boost their enrollment.

To make that happen, however, he said, the formula had to be adjusted so older people at the higher-income end of subsidy eligibility pay more.

“The current ACA discourages younger people from getting in,” said Condeluci, who expects “the older-age lobby will continue to criticize this type of proposal.”

While getting people under the poverty level covered by insurance would be a good thing, it should be done by expanding Medicaid, said Sabrina Corlette, who studies the individual insurance market as research professor at Georgetown University’s Health Policy Institute.

“It’s much more expensive for the federal government to subsidize private insurance than provide a Medicaid benefit,” said Corlette, who also doubts that many people earning less than $12,000 a year have enough saved to cover the cost of a deductible in the types of plans the Senate proposal would subsidize.

In total, the changes proposed in the Senate bill mean, Corlette said, “the subsidy buys you less and the older you are, the more you will be asked to pay.”

Categories: Cost and Quality, Insurance, Repeal And Replace Watch, The Health Law

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Proyecto de salud del Senado cambiaría Medicaid y limitaría apoyo para las primas

Los republicanos en el Senado de los Estados Unidos revelaron el jueves 22 de junio un proyecto de ley que transformaría dramáticamente el programa Medicaid, haría cambios significativos a los créditos tributarios de la ley federal de salud que ayudan a las personas de bajos ingresos a comprar cobertura, y permitiría a los estados cambiar algunas de las garantías de la ley.

El proyecto de ley también deroga los impuestos que financiaron los beneficios de la Ley del Cuidado de Salud Asequible (ACA), lo que resultará en cientos de miles de millones de dólares en recortes de impuestos para los más ricos y para la industria de la salud.

La mayoría de los senadores obtuvieron su primer vistazo a la ley cuando fue publicada el jueves por la mañana, ya que fue elaborada en secreto durante las últimas semanas. El líder de la mayoría del Senado, Mitch McConnell (republicano de Kentucky), está buscando que el proyecto de ley se vote antes que el Congreso empiece la próxima semana el receso del 4 de julio.

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Los senadores habían prometido que su propuesta de reemplazo del ACA sería muy diferente de la versión que aprobó la Cámara Baja en mayo. Sin embargo, el proyecto de ley siguió la dirección de la Cámara en muchos aspectos.

A la velocidad de la luz y con poco más de una semana para una revisión más amplia, el proyecto de ley de los republicanos podría influir en la atención médica y el seguro de salud de cada estadounidense. Al invertir el curso de algunas de las disposiciones más populares de la Ley del Cuidado de Salud Asequible (ACA), amenaza con dejar a decenas de millones de estadounidenses de bajos ingresos sin seguro, y, una vez más, a aquellos con condiciones médicas crónicas o costosas en una posición financiera vulnerable.

Al igual que la medida de la Cámara de Representantes, el proyecto de ley del Senado, que se denomina un “borrador de discusión”, no derogaría completamente ACA, pero anularía muchas de las disposiciones clave de la ley. Ambos proyectos de ley también limitarían -por primera vez en la historia- el financiamiento federal para el programa Medicaid, que cubre a más de 70 millones de estadounidenses de bajos ingresos. Desde su creación en 1965, el gobierno federal ha igualado el gasto estatal para Medicaid. El nuevo proyecto de ley transferiría gran parte de esa carga a los estados.

El proyecto de ley también reconfigura cómo los estadounidenses con ingresos ligeramente altos, que no califican para el Medicaid, obtendrían créditos fiscales para ayudar a pagar las primas de sus seguros, y elimina las sanciones para aquellos que no logran obtener cobertura y para los empleadores que no proporcionan beneficios de salud. También la ley facilita que los estados puedan renunciar a las protecciones de los consumidores establecidas por ACA, que requieren que las compañías de seguros cobren las mismas primas a las personas enfermas y a las saludables, y a proporcionar un conjunto específico de beneficios.

“Acordamos en la necesidad de liberar a los estadounidenses de los mandatos del Obamacare, y las políticas contenidas en el borrador de discusión anularán el mandato individual para que los estadounidenses ya no se vean obligados a comprar seguros que no necesitan o no pueden pagar; también derogará el mandato del empleador para que los estadounidenses ya no vean sus salarios recortados por esta razón”, dijo McConnell en la sala del Senado después de dar a conocer el proyecto de ley. Agregó que el proyecto ayudaría a “estabilizar los mercados de seguros que también están colapsando bajo el Obamacare”.

No está claro si el proyecto de ley pasará la barrera del pleno del Senado. El Senado (como la Cámara) está operando bajo un conjunto especial de reglas presupuestarias que le permiten aprobar esta medida con sólo una mayoría simple, impidiendo que los demócratas pueden alargar el debate cabildeando. Pero el proceso de “reconciliación presupuestaria” se debe realizar bajo reglas estrictas, incluyendo el requisito de que todas las disposiciones del proyecto de ley impacten principalmente en el presupuesto federal, ya sea añadiendo o restando del gasto federal.

Por ejemplo, la legislación que se publica incluye una prohibición de un año de financiación del Medicaid a Planned Parenthood. Esa es una demanda clave de los grupos contra el aborto y algunos conservadores del Congreso, porque Planned Parenthood realiza abortos con fondos no federales. Pero aún no está claro si el parlamentario del Senado permitirá que esa disposición sea incluida en el proyecto de ley.

También todavía está entre signos de preguntas una disposición del proyecto de ley del Senado que permitiría a los estados renunciar a las regulaciones de seguros impuestas por el Obamacare. Muchos expertos en presupuesto dicen que se opone a las reglas del presupuesto del Senado porque el impacto de la financiación federal es “meramente incidental” para la política.

Redactar el proyecto de ley del Senado ha sido una danza delicada para McConnell. Con sólo 52 republicanos, y los demócratas unidos oponiéndose a cambiar la ley de salud, McConnell puede permitirse el lujo de perder sólo dos votos y seguir aprobando la ley con un voto de desempate del vicepresidente Mike Pence. McConnell ha liderado un pequeño grupo de trabajo de senadores -todos hombres- pero incluso algunos de ellos se han quejado de que no pudieron participar plenamente de la configuración del proyecto, que parece haber sido en gran medida escrito por el propio personal de McConnell.

Hasta ahora, McConnell había estado recibiendo quejas de las alas más moderadas y más conservadoras de su partido. Y el proyecto que ha surgido parece tratar de aplacar a ambos.

Por ejemplo, según lo que buscan los moderados, el proyecto de ley reduciría gradualmente la expansión del Medicaid de 2020 a 2024, algo más lentamente que el proyecto de ley de la Cámara de Representantes. Pero finalmente terminaría. El proyecto de ley del Senado también se aparta de los créditos de impuestos fijos de la Cámara para ayudar a pagar los seguros, lo que habría agregado miles de dólares a las primas de las personas más pobres y mayores que aún no son elegibles para el Medicare.

Se espera a principios de la próxima semana un informe de la Oficina de Presupuesto del Congreso (CBO) que estima el impacto del proyecto de ley del Senado sobre las personas y el presupuesto federal. De acuerdo con la CBO, el proyecto de ley de la Cámara Baja,  resultaría en 23 millones de estadounidenses menos con seguro de salud a lo largo de 10 años.

Para los conservadores, sin embargo, el proyecto de ley del Senado impactaría aún más en el Medicaid en años posteriores. El tope impuesto por la Cámara crecería más lentamente que el gasto del Medicaid, pero el tope del Senado crecería aún más lentamente que el de la Cámara. Eso dejaría a los estados con pocas opciones, aparte de aumentar los impuestos, reducir la elegibilidad o reducir los beneficios para mantener sus programas.

Los defensores de la actual ley de salud reaccionaron rápidamente.

El senador Ron Wyden (demócrata de Oregon) se quejó de los cambios en las garantías de cobertura en ACA.

“También quiero hacer una nota especial sobre la disposición estatal de renuncia. Los republicanos han retorcido y abusado de una parte de la Ley de Cuidado de Salud Asequible que escribí para promover la innovación estatal, y la están usando para dar a las compañías de seguros el poder de asediar a las personas”, dijo en un comunicado emitido poco después de que se publicara la ley. “Esto equivale a ocultar un ataque a las garantías básicas de atención de la salud detrás de renuncias estatales, y voy a luchar contra ella en cada oportunidad”.

“El desalmado proyecto de ley de salud del Senado hace que la atención de la salud sea peor para todos: eleva los costos, reduce la cobertura, debilita las protecciones y reduce aún más los fondos para el Medicaid que el odioso proyecto de la Cámara”, dijo en un comunicado Protect Our Care, un grupo de defensa que se opone a los cambios republicanos a la ley de salud. “Ellos escribieron su plan en secreto y se apresuran a votar la semana que viene porque saben el daño que su proyecto de ley les hará a millones de personas”.

Categories: Medicaid, Noticias En Español, Repeal And Replace Watch, The Health Law

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Senate Health Bill Would Revamp Medicaid, Alter ACA Guarantees, Cut Premium Support

Republicans in the U.S. Senate on Thursday unveiled a bill that would dramatically transform the nation’s Medicaid program, make significant changes to the federal health law’s tax credits that help lower-income people buy insurance and allow states to water down changes to some of the law’s coverage guarantees.

The bill also repeals the tax mechanism that funded the Affordable Care Act’s benefits, resulting in hundreds of billions of dollars in tax cuts for the wealthy and health care industry.

Most senators got their first look at the bill as it was released Thursday morning. It had been crafted in secret over the past several weeks. Senate Majority Leader Mitch McConnell (R-Ky.) is seeking a vote on the bill before Congress leaves next week for its Fourth of July recess.

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Senators had promised that their ACA replacement would be very different than the version that passed the House in May, but the bill instead follows the House’s lead in many ways.

At lightning speed and with a little over a week for wider review, the Republicans’ bill could influence health care and health insurance of every American. Reversing course on some of the more popular provisions of the Affordable Care Act, it threatens to leave tens of millions of lower-income Americans without insurance and those with chronic or expensive medical conditions once again financially vulnerable.

Like the House measure, the Senate bill, which is being called a “discussion draft,” would not completely repeal the ACA but would roll back many of the law’s key provisions. Both bills would also — for the first time — cap federal funding for the Medicaid program, which covers more than 70 million low-income Americans. Since its inception in 1965, the federal government has matched state spending for Medicaid. The new bill would shift much of that burden back to states.

The bill would also reconfigure how Americans with slightly higher incomes who don’t qualify for Medicaid would get tax credits to help pay insurance premiums, eliminate penalties for those who fail to obtain insurance and employers who fail to provide it, and make it easier for states to waive consumer protections in the ACA that require insurance companies to charge the same premiums to sick and healthy people and to provide a specific set of benefits.

“We agreed on the need to free Americans from Obamacare’s mandates, and policies contained in the discussion draft will repeal the individual mandate so Americans are no longer forced to buy insurance they don’t need or can’t afford; will repeal the employer mandate so Americans no longer see their hours and take-home pay cut by employers because of it,” McConnell said on the floor of the Senate after releasing the bill. He also noted that the bill would help “stabilize the insurance markets that are collapsing under Obamacare as well.”

It is not clear that the bill will make it through the Senate, however, or that all of it will even make it to the Senate floor. The Senate (like the House) is operating under a special set of budget rules that allow it to pass this measure with only a simple majority vote and block Democrats from dragging out the debate by using a filibuster. But the “budget reconciliation” process comes with strict rules, including the requirement that every provision of the bill primarily impact the federal budget, either adding to or subtracting from federal spending.

For example, the legislation as released includes a one-year ban on Medicaid funding for Planned Parenthood. That is a key demand of anti-abortion groups and some congressional conservatives, because Planned Parenthood performs abortions with non-federal funding. But it is not yet clear that the Senate parliamentarian will allow that provision to be included in the bill.

Also still in question is a provision of the Senate bill that would allow states to waive insurance regulations in the Affordable Care Act. Many budget experts say that runs afoul of Senate budget rules because the federal funding impact is “merely incidental” to the policy.

Drafting the Senate bill has been a delicate dance for McConnell. With only 52 Republicans in the chamber and Democrats united in opposition to the unraveling of the health law, McConnell can afford to lose only two votes and still pass the bill with a tie-breaking vote from Vice President Mike Pence. McConnell has been leading a small working group of senators — all men — but even some of those have complained they were not able to take part in much of the shaping of the measure, which seems to have been largely written by McConnell’s own staff.

So far, McConnell has been fielding complaints from the more moderate and more conservative wings of his party. And the draft that has emerged appears to try to placate both.

For example, as sought by moderates, the bill would phase down the Medicaid expansion from 2020 to 2024, somewhat more slowly than the House bill does. But it would still end eventually. The Senate bill also departs from the House bill’s flat tax credits to help pay for insurance, which would have added thousands of dollars to the premiums of poorer and older people not yet eligible for Medicare.

A Congressional Budget Office report estimating the Senate bill’s impact on individuals and the federal budget is expected early next week. The House bill, according to the CBO, would result in 23 million fewer Americans having health insurance over 10 years.

For conservatives, however, the Senate bill would clamp down even harder on Medicaid in later years. The cap imposed by the House would grow more slowly than Medicaid spending has, but the Senate’s cap would grow even more slowly than the House’s. That would leave states with few options, other than raising taxes, cutting eligibility, or cutting benefits in order to maintain their programs.

Defenders of the health law were quick to react.

Sen. Ron Wyden (D-Ore.) complained about changes to coverage guarantees in the ACA.

“I also want to make special note of the state waiver provision. Republicans have twisted and abused a part of the Affordable Care Act I wrote to promote state innovation, and they’re using it to give insurance companies the power to run roughshod over individuals,” he said in a statement issued shortly after the bill was released. “This amounts to hiding an attack on basic health care guarantees behind state waivers, and I will fight it at every turn.”

“The heartless Senate health care repeal bill makes health care worse for everyone — it raises costs, cuts coverage, weakens protections and cuts even more from Medicaid than the mean House bill,” said a statement from Protect Our Care, an umbrella advocacy group opposing GOP changes to the health law. “They wrote their plan in secret and are rushing forward with a vote next week because they know how much harm their bill does to millions of people.”

Categories: Medicaid, Repeal And Replace Watch, The Health Law

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