In 2017, more than 11 million people are projected to be covered by policies purchased through the Affordable Care Act (ACA), and even those who have private insurance are benefiting from reforms put into place by the passage of Obamacare. Now, a Republican-controlled Congress plans to repeal the ACA as their first act back in session, and President-elect Donald Trump has agreed to sign whatever they send him.
But while "repeal and replace" is catchy and apparently wins elections, the GOP still hasn't agreed on when each part of Obamacare's repeal will go into effect, and whether they will include some popular reform planks when they introduce their own replacement plan. While Republicans are insistent that their own plan is in the works, nothing has been released to the public — despite the fact that they have voted repeatedly to repeal the ACA ever since they took the majority in the House in 2011. The delay is purposeful, since many aspects of the Affordable Care Act are extremely popular and constituents don't want to see them disappear, especially with no replacement plan on the horizon.
How will voters help shape what the "repeal and replace" process looks like? Here are some of the biggest benefits you received thanks to the Affordable Care Act, and how likely it is that each benefit will completely disappear.
Policy: Staying on parental plans until age 26
Currently, you can stay on your parents' health insurance without needing to find your own plan — at least, you can until you are 26. That means not purchasing a more expensive individual plan, which would cost more out of pocket. Taking away the extended minors portion of the ACA will mean once you turn 19 or are no longer a full-time student, you are on your own for insurance coverage, increasing the financial burden on young adults who are unemployed, underemployed, contractors, working for small companies, or those starting their own businesses.
Will it stay or will it go?
While Republicans don't like Obamacare in total, allowing adult children to remain on parents' accounts is one thing that many Congress members are fond of — and apparently a number of sitting Republican politicians take advantage of it for their own family members. According to the Huffington Post, a number of states were already allowing those in their late teens and early 20s to remain on their parents' insurance plans even before the ACA passed, and the popular provision will more than likely be added to whatever replacement the GOP drafts, although the age limit could potentially get lowered by a year or two. With the extended minors portion of health reform adding lots of low-risk insurees to the pool (people that will pay premiums but not cost much in medical expenses), you can expect both Republicans and insurance companies to want this policy change to remain.
Policy: Forbidding insurers from denying coverage for pre-existing conditions
Those who were uninsured prior to enrolling in state or federal insurance plans often were unable to get coverage due to previously existing medical conditions that made them higher-risk, such as cancer, pregnancy, chronic illnesses, diabetes, asthma, or mental health issues, making them unappealing clients to for-profit insurance companies. Approximately 1 in 4 Americans have a pre-existing medical condition that could make it difficult to find insurance, and about 3 million of them are now insured under Obamacare plans. When the ACA is repealed, those who have insurance could lose it and those without insurance, or who leave their old plans for any reason such as job change, divorce, or relocation, may find it impossible to get a new plan.
Will it stay or will it go?
Like the rule allowing young adults to stay on their parents' insurance plans, the pre-existing condition reform is a very popular change among the general public. Unfortunately insurance companies aren't as big of a fan, since that means covering more patients who use more services that insurers must reimburse. But kicking a few million sick customers off insurance — or telling millions more that they are uninsurable in the first place — isn't going to poll well when politicians are up for reelection.
"There are a few ideas for finessing that problem away, such as creating a series of 'high-risk pools' or a single federal high-risk pool for sick people seeking health insurance," explains Kevin D. Williamson at the conservative site National Review. "What this means is that the sick people without insurance who want it would go into a separate insurance pool full of other people likely to require lots of expensive medical care." Of course, as Williams points out, the "high risk" pools would include far more expensive plans that many would find difficult to afford, requiring some sort of government subsidies — one of the biggest reasons why the GOP was against Obamacare in the first place. Until they can figure out some way to reconcile the two, the current rule on covering those with preexisting conditions will likely stay in place.
Policy: Individual mandate to have health insurance
One of the biggest pieces of the Affordable Care Act was its requirement that every person have health insurance and that each plan have a minimal amount of coverage for basics like no co-pay birth control, mental health care, substance abuse treatment, yearly physicals, prescription drug coverage, and maternity care. By making insurance a requirement — and making those who were not insured pay a fine in order to persuade them to get their own plans — the Obama administration expected that the insurers would be flooded with healthy, young customers who would bring down the costs of the medical care for those who were higher-risk. However the GOP hated the mandate, which they argued was unconstitutional and infringed on the rights of American citizens. The Supreme Court disagreed and the mandate stayed.
Will it stay or will it go?
Oh, it's going for sure. Politicians have compared mandating all citizens have minimal insurance plans to "slavery" or "the Holocaust." Republicans have been trying to eliminate just the individual mandate itself even outside of mass Obamacare repeals, so expect it to be put into effect immediately once repeal is signed and for no similar proposal to be added into whatever replacement the GOP drafts. That's good news for those who want to go back to "catastrophic" insurance coverage — plans with extremely low monthly payments and very high deductibles, meant only to protect someone if that person has a major medical event like cancer or a debilitating auto accident — or for those who want to press their luck and go without any insurance all together. But it's not such good news for the rest of the insured, since it will probably cause everyone else's costs to increase as low-risk insurees remove themselves from the pool.
Policy: No co-pay birth control
For the millions of people of reproductive age, Obamacare's major impact was in allowing them to access birth control without monthly co-pays at a pharmacy or to obtain long-lasting reversible contraceptives like IUDs without paying hundreds of dollars out of pocket. According to a Guttmacher study, the percentage of insurees who were able to obtain no co-pay birth control methods in the first 18 months that the birth control mandate went into effect increased dramatically from as little as 15 percent to 74 percent, depending on the type of contraception. That's millions of dollars saved by women that could then be used for other expenses.
Will it stay or will it go?
Not only is the birth control mandate on the rocks, the GOP may not even need an Obamacare repeal to end it. President-elect Donald Trump's Department of Health and Human Services (HHS) can attack it themselves once they are seated, both by allowing more exemptions for companies or nonprofits that object to the coverage on religious grounds, or by writing a specific rule to remove the mandate by redefining "preventative healthcare for women." Considering likely HHS Secretary Rep. Tom Price of Georgia once said he doubted anyone could find one person who couldn't afford to buy her own birth control, the future of the mandate looks pretty grim.
The silver lining? Even with a repeal or a new rule in place ending no co-pay birth control, it will take some time for a new policy to go into effect. Revising or repealing the contraception mandate would be "more complicated than just flipping a switch," Alina Salganicoff, vice president and director of women's health policy at the Kaiser Family Foundation, told McClatchy News Service after the election. Any rule that is introduced will have a period for commenting before it can be enacted, and insurance plans can't change their policies overnight. More likely it would stay in effect until the next enrollment period, usually just before the end of the year. So if the mandate is removed, at least there will be time to prepare for it by stocking up on emergency contraception or getting long-lasting contraception.
Policy: Medicaid expansion and government subsidies
One of the most appealing aspects of health-care reform for many was the ability to get subsidized insurance policies, reducing out-of-pocket costs. According to Kaiser Health News, all but 19 states expanded the income limits for people to get insured under Medicaid — some to as much as 300 percent of the federal poverty level — and tax credits beyond that also helped even middle-class workers and families afford their monthly premiums. In essence, government subsidies are what put the "affordable" into the Affordable Care Act.
Will it stay or will it go?
Based on the resistance that red states had to expanding Medicaid coverage in the first place — even with the federal government covering almost all of the expense — it will not be surprising to see a GOP plan that either decreases or completely removes tax credits or other subsidies. This is the one aspect of the Republican replacement that has everyone guessing as to what could happen next. The most likely scenario is that states will be given block grants for Medicaid funding, which would allow states to decide how much to subsidize plans for lower-income residents, potentially in the form of Heath Savings Accounts. Meanwhile, tax credits for people who buy private health insurance will stay in place but be shifted to consider a person's age — not income — when determining the size of the credit.
According to Stephen Parente, who worked with the conservative think tank the American Action Forum, the "Better Way" replacement plan that was drafted with approval from Speaker of the House Paul Ryan and Trump's pick for HHS secretary, Tom Price, would remove income as a factor altogether when it came to subsidies and rely only on a person's age. "[T]ax credits in Better Way are indexed and sized to a person's age. ... Someone who is age 60 might be getting a $5,000 credit for themselves. They might get only $1,500 if they're, say, 35 years old," he told the Minneapolis Star Tribune in a December interview. While that might be a great bargain for a healthy retiree, it could be a major struggle for the 20- or 30-year-old who would then be forced to pay most of their premium costs out-of-pocket – even before they get to their deductibles on any health care they use. Then again, without an individual mandate to have insurance in the first place, they may end up just tempting fate and going without any coverage at all.
Policy: Gender parity, minimum benefits coverage, lifetime caps, and mandating large companies to obtain insurance plans for their employees
While Obamacare's biggest reforms were to get all Americans insured regardless of their health or income, many of the less-championed points of the ACA greatly affected patients of all ages, genders, and economic means. Because of the ACA's passage, all insurance plans had to include preventative care, maternity care, substance abuse treatment programs, and other basic health care. Also, insurers were not allowed to charge women more for their plans than they did men, a practice that was more common before the law went into effect due to an unsupported claim by insurance companies that women use more health services than men. Insurance companies also can no longer set annual or lifetime coverage caps, which would allow them to stop paying if a patient has extensive medical issues that drive hospital bills through the roof, a policy that often sent patients into bankruptcy. And companies with more than 50 full-time employees are required to offer health insurance to their employees or face fines for refusing.
Will they stay or will they go?
Like the individual mandate itself, all of these other Obamacare policies are almost certainly heading out the door at some point after the repeal vote and are unlikely to be included in any sort of GOP replacement. Republicans campaigned on the idea that Obamacare was government intrusion into the health-care industry, and any sort of regulation on how much a plan will cost, what procedures must be covered, or whether businesses have to participate would conflict with everything they promised on the trail. The GOP convinced their supporters that true "freedom" means the right to have absolutely minimal health insurance coverage or no coverage whatsoever, and for businesses and nonprofits to opt out of covering their employees as well. And if a large portion of the American population returns to using emergency rooms as primary care because seeing a doctor is too expensive, well, at least they can say they kept the government out of health care.