Obamacare vs. AHCA and BCRA
Some of the big differences
between the Affordable Care Act, the House’s American Health Care Act and the Senate’s Better Care Reconciliation Act are:
Medicaid Medicaid expansion
ACA: Enhanced federal match for expansion population is 95% this year, 94% next year, 93% in 2019 and 90% in 2020 and beyond
AHCA: Match would remain as described in ACA until 2020, with the enhanced match until beneficiaries cycle out of the program.
BCRA: 90% match in 2020; 85% in 2021; 80% in 2022; 75% in 2023. No grandfathering. After 2023, federal contribution is based on general state match percentage.
Current law: States design plans, provider payment levels and eligibility. Federal match rate varies depending on the wealth of the state, ranging from 50% to 73%.
AHCA: In 2020, a per capita cap that could grow by either the medical component of the Consumer Price Index or medical CPI plus 1 percentage point. The aged and disabled adults would be under the more generous per capita cap. Each state’s base figure would be based on historic per enrollee spending.
BCRA: Per capita cap takes effect in 2020, excludes children who are on disability. In 2025, the cap would grow at standard inflation, a much lower rate than medical CPI. States could set the base rate.
Individual market Cost-sharing-reductions:
Current law: Continue to be paid to insurers. AHCA: Paid in 2019 and 2020 only. BCRA: Same as the AHCA.
Current law: Available to persons or families between 138% and 400% of federal poverty level, as long as they don’t have access to affordable plans through work. Are based on age, income and local cost of insurance.
AHCA: Available for everyone except those insured through work. Agebased only and more generous than current law to younger customers.
BCRA: Available to those below 350% of poverty. Based on age, income and local cost of insurance. Those age 50 and older, starting at 200% of poverty, receive lower subsidies than under the ACA; 60- to 64-year-olds could have to spend as much as 16% of their income on premiums before subsidies, compared to 9.7% in the ACA.
Essential health benefits, medical underwriting, pre-existing conditions
Current law: 10 essential health benefits, such as prescription drugs, maternity care and mental health care are mandated. Plans must sell to everyone and cannot charge sick people more.
AHCA: States may apply for waivers to drop essential benefits or the rules on charging sick people more, but those changes only apply to those who did not maintain continuous coverage.
BCRA: States may apply for waivers, but not for rejecting sick applicants or charging them more.
Individual and employer mandates
Current law: Everyone must have insurance or face a tax penalty. Companies with at least 50 employers are required to offer insurance.
AHCA: Those who don’t buy insurance can be charged 30% more per month for one year when they try to come back in. No employer mandate.
BCRA: No mandates.
Current law: Taxes on insurers, hospitals, medical-device manufacturers, rich employer-based plans and investment income, among others, help pay for the expansion. Some of those taxes, especially the Cadillac tax on rich employer plans, were so unpopular they were never implemented. The investment income tax is the biggest funder.
AHCA: The taxes are repealed, though not all immediately.
BCRA: The taxes are repealed, some retroactively, such as the investment tax, and some in 2018 and 2023. The Cadillac tax is temporarily repealed, but returns in 2026.