Q&A: What Does The Senate Health Bill Mean For Me?

Jun 27, 2017

Since Senate Republicans released the draft of their bill to repeal and replace the Affordable Care Act last week, many people have been wondering how the proposed changes will affect their own coverage, and their family's: Will my pre-existing condition be covered? Will my premiums go up or down?

The bill is still a work in progress, but we've taken a sampling of questions from All Things Considered listeners and answered them, based on what we know now.


Q: My husband and I are both in our 50s, self-employed, and we have a daughter in college. We buy insurance through the California exchange. Our family premium is now $1,100 a month with a deductible of $6,800 per person. We have never received a subsidy.

Three months ago, I was diagnosed with breast cancer. It was early stage, and I am in treatment with no cancer remaining. We are all very active and healthy otherwise.

Here is my concern: Based on what I have read, it appears our age group stands to see the biggest jump in premium costs. Not to mention, I now have a pre-existing condition. Will our premiums rise astronomically?

-- Denise Estrada, Los Angeles, Calif.

A: This is a double-barreled question on premium costs and pre-existing conditions, both major concerns to consumers.

For a person in their 50s, worries about premium increases are well-founded. Under the Affordable Care Act, insurance companies are allowed to charge older people up to three times more than young people for the same insurance policies.

The Republican health care bills in both the Senate and House would allow insurers to charge up to five times more.

That change would likely lead to cheaper health plans for younger people, but also more expensive ones for those over 50. The Kaiser Family Foundation estimates that a 60-year-old in Los Angeles County who doesn't qualify for subsidies would see her premium rise about $2,600 a year.

As for your question about your pre-existing condition, the answer would depend on where you live. The Senate bill does preserve the pre-existing condition protections that exist under the Affordable Care Act — meaning insurance companies must offer you a policy even if you have a medical problem. But it would also allow states to ask for waivers from some federal regulations, including those that define "essential health benefits." If a state doesn't include cancer treatment or pharmaceutical coverage in those benefits, then insurance companies can elect not to pay for some of the care you need.

Q: My 2 1/2-year-old son has been through eight hospitalizations and is fed partly through a feeding tube. We have insurance through my husband's employer, and our son qualified for Medicaid last November because of a program in Pennsylvania for children with chronic illnesses.

The medical bills we've already seen would have been catastrophic without insurance, and our out-of-pocket medical expenses were thousands of dollars a year, even with insurance, before he qualified for Medicaid. His medical care needs have been so intense that I have not been able to work this past year.

We are very worried about his future care costs without Medicaid, as well as our ability to afford insurance coverage for him if pre-existing conditions are not afforded any legal protections.

How is Trumpcare likely to affect our family?

-- Emily Kane, Pittsburgh, Pa.

A: It sounds like Pennsylvania's Medicaid program has been helpful for your child. Under the proposed law, states will have even more power to design their own Medicaid programs, so there's no reason to think that Pennsylvania would take away a local program that it has implemented.

What might be worrisome, however, are the overall reductions to the Medicaid program. The bill turns Medicaid from an open-ended program that pays for all the care beneficiaries need, to one that caps federal spending based on the number of people enrolled. The Congressional Budget Office predicts that if the Senate bill passes, Medicaid spending would be 26 percent lower, over the next decade, than it would be under the Affordable Care Act.

Some analysts believe that over time, states will have to cut services, reduce how much they pay doctors and hospitals and make it harder to qualify for Medicaid.

Q: My wife and I are both 42, and we have two children, ages 10 and 13. We have coverage through the marketplace but do not qualify for payment assistance. In addition, my wife has rheumatoid arthritis and currently uses expensive monthly injections to treat it. Would insurance still be required to cover my wife's arthritis treatment under the new law? And how would our premiums be affected?

-- Jeremy Merrill, Cedar Park, Texas

A: As far as premiums go, it looks like yours are likely to remain about the same. The Kaiser Family Foundation estimates that for a 40-year-old in Williamson County, Texas, who doesn't qualify for subsidies, premiums are flat under the new law.

Whether your insurance will cover your wife's condition depends largely on your governor. As I explained above, states can ask for waivers from many of the Affordable Care Act's consumer protections, including those that define what medical services insurers have to cover.

Q: My 16-year-old daughter has Crohn's disease. She requires Remicade infusions every six weeks. Each infusion costs $20,000. I am very concerned about lifetime maximums being reinstated. Additionally, I worry that children will no longer be able to stay on their parents' insurance policies until 26, and that pre-existing conditions will result in higher premiums, even for employer-sponsored plans.

-- Amy Lowe, Dayton, Ohio

A: You only have to worry about one of those things.

The Senate bill does include the very popular provision in the Affordable Care Act that allows children to stay on their parents' health insurance policy until they are 26.

However, there is a chance that lifetime spending limits and annual limits [to what an insurer would pay for the care of a given patient] could return. Before the Affordable Care Act, about 60 percent of employers had lifetime limits on their health plans. The section of the bill that allows states to get waivers from federal rules opens the door to those limits making a comeback — even in employer-sponsored policies.

Copyright 2017 NPR. To see more, visit http://www.npr.org/.

ROBERT SIEGEL, HOST:

We've received a lot of questions from listeners about what the Republican proposals could mean for them and their families. And NPR health policy correspondent Alison Kodjak has been sorting through them with our producers, and she's here to answer a few of them. Hi, Alison.

ALISON KODJAK, BYLINE: Hi, Robert.

ARI SHAPIRO, HOST:

The first listener we're going to hear from has a very common situation. Here she is.

DENISE ESTRADA: My name is Denise Estrada, and I live in Los Angeles, Calif. My husband, Rick (ph), and I are both self-employed, and we're both in our early 50s with one daughter in college. And we get our health care through the California exchange. We use Kaiser. Our family premium now costs us about $1,100 a month, so we're looking at about $16,000 a year just for our premiums not including our deductible, and we do not receive a subsidy.

So here's my concern. Based on what I've read and what I've watched on television, it appears that our age group - we're not retired yet, but we're over the age of 50. We stand to see the biggest increase in our premium cost. So there's a lot of stress about that because it's a big unknown. Will our premiums rise astronomically due to our ages?

KODJAK: You know, that's a valid concern. This bill does allow insurers to charge older people more than they do now, and the Affordable Care Act has limits on that. It allows insurers to charge older people three times more than it charges the youngest. This bill allows that to go up to five times more. So the hope is that it will lower premiums for younger people. But at the same time, the Congressional Budget Office says it's going to raise premiums for older people. And I actually looked up Mrs. Estrada's specific situation. The Kaiser Family Foundation has this little widget, and a 60-year-old in Los Angeles County who doesn't qualify for subsidies is likely to see her premium increase $2,600 a year.

SIEGEL: Now, we also heard from listeners who are anxious about the potential introduction or perhaps reintroduction of lifetime maximums for insurance coverage.

AMY LOWE: My name is Amy Lowe, and I'm from Dayton, Ohio. We get our insurance through my husband's employer. My daughter is 16 years old, and she has Crohn's disease, which is an autoimmune condition that affects her small and large intestine. She requires infusions of a drug called Remicade every six weeks, and each infusion costs $20,000. So I would like to know if lifetime maximums are in fact being considered. And if so, what happens to people like my daughter?

KODJAK: And that's a really good question. It's a complicated answer. The Affordable Care Act does ban lifetime limits on benefits. And those protections are at risk because states under this bill are allowed to ask for waivers from those consumer protections, those regulations that are in Obamacare that define what insurance companies have to cover. And because of some loopholes in the law, even if just one state gets a waiver from those, all large employers can opt into those rules.

So if a state gets a waiver from lifetime limits, there could be a lot of insurance policies, even those you get through employer, that might have a $1 million, $2 million, $5 million limit. And it's not really a theoretical question because before the Affordable Care Act, almost 60 percent of employer plans had a lifetime limit on it.

SHAPIRO: And of course a lot of people who use Medicaid are wondering what the future might hold for them. Let's listen to this.

EMILY KANE: My name is Emily Kane, and I live in Pittsburgh, Pa. My son's 2-and-a-half years old, and he qualified for Medicaid through a clause that allows children who are chronically ill to receive Medicaid support. He has an endocrine disorder called adrenal insufficiency. In order to get him back to health and stability, he's needed the assistance of a feeding tube, which is now surgically placed. So I'd like to know how the GOP's health care bill will affect our family's financial future and the future of my son's medical care.

KODJAK: That's a tough one. Obviously it's impossible to know exactly how this bill will play out over that much time. The Medicaid program that helped her son specifically is a state program. A lot of Medicaid programs can be implemented by the states. And so this is a Pennsylvania-specific program. The law - the proposed bill in the Senate would actually give states more power to regulate and implement their Medicaid program. So there's no reason to think this specific program's at risk, but Medicaid's also facing enormous cuts. The CBO says that in 10 years, there's going to be 26 percent less money for Medicaid. So that's where the concern is - whether the benefits will be there.

SHAPIRO: NPR's Alison Kodjak answering your questions about the health care proposal. Thanks very much.

KODJAK: Thanks, Ari.

SIEGEL: And if you have questions about the Republican health care proposals, email them to us at nprcrowdsource@npr.org, and put health care in the subject line. And tomorrow morning, we'll hear what the Senate bill would mean for veterans. Most of them receive health care through Medicaid or the exchanges, not through the VA. Listen for that and more as you begin your day with MORNING EDITION. Transcript provided by NPR, Copyright NPR.