Winners, losers complicating GOP’s path

WASHINGTON» Republicans’ latest health care plan would create winners and losers among Americans up and down the income ladder and across age groups.

As Senate Majority Leader Mitch McConnell, R-Ky., steers toward debate and votes next week, here is a look at some of the latest changes and major issues:

• Cruz’s plan: The new Senate bill incorporates a proposal from Sen. Ted Cruz, R-Texas, that would reorganize the market for policies purchased by individuals. As many as 20 million Americans get coverage this way, about half through subsidized markets like HealthCare.gov, created under former President Barack Obama.

Cruz would change basic requirements that Obama’s law imposed on individual plans, including standard benefits such as pregnancy, maternity and newborn care; wellness visits and mental health treatment.

Under the Cruz approach, an insurer can offer plans that don’t comply with such requirements, provided they also offer coverage that does. The problem, say critics, is that the healthy would flock to low-premium, skimpy plans, leaving the sick to face escalating prices for comprehensive coverage.

The latest bill includes another $70 billion to help states keep health insurance affordable for older, sicker customers.

Some insurers are worried because health plans that enroll healthier customers would no longer have to cross-subsidize those with sicker patients, as is currently required. • Employer escape hatch? McConnell’s new bill made a major change to tax-sheltered health savings accounts, which was also advocated by Cruz.

Under the bill, health savings accounts could be used to pay premiums with pretax money. Under current law, they can only be used to cover out-of-pocket costs, such as deductibles and copayments.

The change is meant to level the playing field for people buying individual plans, as compared to people getting employer coverage. The value of workplace insurance is tax-free for employees and tax-deductible for employers.

But some analysts say McConnell risks undermining workplace coverage.

The upside is that the change might encourage more self-employed people to buy individual health insurance policies. The downside is that some employers may see it as an invitation to drop health benefits, particularly since the GOP also would repeal Obama’s requirement that larger companies provide health care or face fines. • The poor and the sick: McConnell kept some Obama-era tax increases used by Democrats to finance expanded coverage. But the money will shore up private insurance, not the Medicaid program. Medicaid accounts for half or more of the 20 million Americans gaining coverage as a result of the Affordable Care Act.

Medicaid covers low-income people, from pregnant women and newborns, to disabled people and elderly nursing home residents. The GOP bill would start by phasing out enhanced federal financing for Obama’s Medicaid expansion, adopted by 31 states. It would limit future federal funding for the overall program. It’s estimated Medicaid would cover 15 million fewer people by 2026.