WHEN TRUMP­CARE KICKS IN A look at who loses in­sur­ance, who pays more and why.

Eco­nomic pol­icy an­a­lyst Ja­cob Leiben­luft lays out the time­line for the mea­sure’s im­ple­men­ta­tion

The Washington Post Sunday - - OUTLOOK - Twit­ter: @jleiben­luft

House Repub­li­cans, ea­ger to up­end the Af­ford­able Care Act (ACA), have passed a bill that in­de­pen­dent ar­biters such as the Con­gres­sional Bud­get Of­fice say would in­crease the num­ber of unin­sured by mil­lions, cut Med­i­caid by $800 bil­lion, and raise pre­mi­ums and de­ductibles — es­pe­cially for those with pre­ex­ist­ing con­di­tions. But if this leg­is­la­tion, in its cur­rent form, is even­tu­ally en­acted, the fall­out won’t come im­me­di­ately or all at once. It’s likely to take place over sev­eral years, in a se­quence of events af­fect­ing tens of mil­lions of peo­ple. Here’s a glimpse of how the next few years might un­fold un­der the Amer­i­can Health Care Act (AHCA) if it be­comes law: Sum­mer 2017: In their an­nual re­port on the state of Medi­care, the pro­gram’s trustees an­nounce that, mainly be­cause it rolls back taxes on high-in­come house­holds that fund the pro­gram, the AHCA will ac­cel­er­ate the de­ple­tion of Medi­care’s Hospi­tal In­sur­ance Trust Fund as less rev­enue comes in. Mean­while, be­cause the AHCA elim­i­nates the penalty for not hav­ing cov­er­age, in­sur­ers an­nounce that they’re can­cel­ing plans or sharply rais­ing pre­mi­ums for 2018 out of fear that more healthy peo­ple will opt not to get in­sur­ance, leav­ing plans over­loaded by sick peo­ple who are more ex­pen­sive to cover. Nov. 1, 2017: “Open en­roll­ment,” the pe­riod when po­ten­tial en­rollees can sign up for health in­sur­ance plans for the fol­low­ing year, be­gins for the first time un­der the AHCA. Log­ging onto (let’s call it) Trump­care.gov, peo­ple find that they’ll pay sub­stan­tially higher pre­mi­ums com­pared with prior years, and many of their plans are no longer avail­able. With in­sur­ers now per­mit­ted to charge older peo­ple as much as five times what they charge younger in­di­vid­u­als — in­stead of three times or more un­der Oba­macare — older Amer­i­cans see their pre­mi­ums soar. What’s more, the AHCA’s tax cred­its for many older peo­ple are less gen­er­ous than the ACA’s were, so they have less help with pay­ments.

Nov. 1, 2018: Open en­roll­ment be­gins again, and now states — un­der pres­sure to sta­bi­lize their in­sur­ance mar­kets — are let­ting in­sur­ers charge peo­ple with pre­ex­ist­ing con­di­tions more, so long as they re­ceive an eas­ily ob­tain­able fed­eral waiver. In states with waivers, peo­ple sign­ing up on Trump­care.gov are asked for their med­i­cal his­tory, and they face much higher pre­mi­ums or must buy cov­er­age through sep­a­rate high-risk pools if they have pre­ex­ist­ing con­di­tions.

Spring/sum­mer 2019: The 31 states, plus the District, that ex­panded Med­i­caid un­der the ACA will be­gin bear­ing much more of the cost in 2020, so most or all en­act leg­is­la­tion to close their ex­pan­sions to new en­rollees — or else raise taxes or make painful cuts else­where — as they fi­nal­ize their bud­gets for the up­com­ing year, mark­ing the first step to­ward end­ing an ex­pan­sion that has cov­ered more than 11 mil­lion peo­ple. States also tighten Med­i­caid el­i­gi­bil­ity re­quire­ments and re­duce ben­e­fits and provider pay­ments. Mean­while, states will now have to cover any un­ex­pected Med­i­caid costs due to a health cri­sis with­out fed­eral help, forc­ing them to raise taxes or cut other ser­vices if they’re go­ing to re­spond.

Nov. 1, 2019: Mil­lions of con­sumers face ad­di­tional, sharp in­creases in what they must pay to get cov­er­age, as well as for de­ductibles and out-of-pocket costs, as the ACA tax cred­its are re­placed with less-gen­er­ous ones and “cost-shar­ing sub­si­dies” are re­pealed with­out any sub­sti­tute. Con­sumers in the mar­ket­place will re­ceive an av­er­age of $2,200 less in premium tax cred­its, ac­cord­ing to fore­casts from the Cen­ter on Bud­get and Pol­icy Pri­or­i­ties; in 12 high-cost states, the av­er­age drop will be at least $3,000. For older and sicker con­sumers, the price tag is even higher. Mean­while, de­ductibles and other out-of-pocket costs rise by an av­er­age of $1,200 per con­sumer. For ex­am­ple, a low-in­come 60-year-old in West Vir­ginia ends up pay­ing nearly $12,000 more per year for in­sur­ance, while her other out-of-pocket costs in­crease by an ad­di­tional $1,400.

In ad­di­tion, con­sumers in sev­eral states find that their in­sur­ance no longer cov­ers “es­sen­tial health ben­e­fits,” such as ma­ter­nity care and men­tal health ser­vices; doesn’t mean­ing­fully cap out-of-pocket costs; and ef­fec­tively re­stores pre-ACA an­nual and life­time lim­its. Women in th­ese states dis­cover that, just like be­fore the ACA, they must pay more be­cause of the added cost of ma­ter­nity cov­er­age. Jan. 1, 2020: In most states, the Med­i­caid ex­pan­sion is closed to new en­rollees. Mil­lions of peo­ple who in 2017 ben­e­fited from the ex­pan­sion have cy­cled off the pro­gram, even though they’ll need cov­er­age again if they lose a job or an em­ployer cuts their hours.

2020 and beyond: The num­ber of unin­sured Amer­i­cans con­tin­ues to rise as fewer peo­ple en­roll in the in­di­vid­ual mar­ket. The Med­i­caid ex­pan­sion ef­fec­tively ends by 2024. States have to make deeper cuts to their Med­i­caid pro­grams each year be­cause of shrink­ing fed­eral funds. Peo­ple who are lower-in­come, have pre­ex­ist­ing con­di­tions or are older dis­pro­por­tion­ately find them­selves with­out cov­er­age and forgo needed care.

House mem­bers passed a bill they had only a few days to re­view. Per­haps, know­ing all the above, the Se­nate will be more ju­di­cious. Ja­cob Leiben­luft is a se­nior ad­viser at the Cen­ter on Bud­get and Pol­icy Pri­or­i­ties, a for­mer deputy di­rec­tor of President Barack Obama’s Na­tional Eco­nomic Coun­cil and a se­nior pol­icy ad­viser for Hil­lary Clin­ton’s 2016 pres­i­den­tial cam­paign.

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