How Would The Republican Health Care Bills Affect You?

Senate Republicans have released the latest draft of their bill to repeal and replace the Affordable Care Act. Here's a chart that outlines how it affects different groups of people. NPR has answered listener questions and talked to the experts. Here's a summary of how it would affect people in New York and New Jersey.

Rates for 2017 are set, so your existing plan will stay the same price through the year. But insurance companies are frustrated by much of the uncertainty over the future of the Affordable Care Act since President Trump's election. They need to prepare to sell policies for 2018 while not knowing which laws will apply. Many insurers are starting to make proposed rates for next year public but point out that rates would be higher if the legislation passes. Both the House and Senate legislation repeal the individual mandate requiring that people have insurance, and the Trump administration has doled out cost-sharing payments a month at a time. In the Senate's bill, they are promised to insurers through 2020 before ending completely. If certain cost-sharing payments to insurers don't get paid and/or the individual mandate disappears, insurers in Pennsylvania say they will ask the state's regulators rate for hikes of between 20 percent and 36 percent. If the Affordable Care Act remains in place, Pennsylvania insurers will ask for a 9 percent raise. Florida Blue, that state's largest insurer, has said the same thing — it would have to raise insurance rates by an additional 20 percent if those payments end. That is in addition to the average increase of 17.8 percent all Florida individual plans have asked state regulators for next year. Blue Cross Blue Shield of Montana is proposing that rates go up 23 percent because of the uncertainty. Other insurers in the state are providing rates based on the assumption that the ACA will remain in place and are asking for single-digit increases. They all say that people losing health insurance — either their exchange plan or Medicaid — will result in insurance being more expensive for everybody.

No. The GOP bills get rid of the requirement that individuals have insurance. Both bills also repeal the mandate that employers offer insurance.

Both the House and Senate plans keep subsidies in some form, but the amount the federal government would pay out would be lower. In the Senate bill, starting in January 2020, subsidies would be available to people living at 350 percent of the federal poverty level ($41,600) or less but would be less generous for most recipients as a percentage of their premium. Under the House bill, tax credits would be based primarily on age, starting at $2,000 for those younger than 30 and capping out at $4,000 from ages 60 to 64, adjusted for inflation in subsequent years.

What you pay would depend on which state you live in and what benefits would be included in your plan. Some people would see lower premiums, especially in states that opt out of consumer protections and let insurers sell plans with fewer benefits. However, for people who want plans that cover the essential health benefits mandated by the Affordable Care Act — including mental health coverage, addiction treatment, maternity care and prescription drug coverage — costs could go way up. A Kaiser Family Foundation study found that under the Senate bill, most people's premiums would rise and that average marketplace consumers would pay 74 percent more toward their premium for a benchmark silver plan in 2020 than under current law. Under the House bill, the Kaiser Family Foundation found that younger people would pay less and people who are older, have lower incomes or live in high-cost areas would pay more.

Under the House bill, people who buy insurance on the individual market and have a break in their health insurance coverage of more than 63 days in a year would be hit with a 30 percent premium surcharge for the year after they buy a new plan. The penalty would kick in only when people try to buy coverage after a break and, because it is based on a plan's premium, would likely have a greater impact on older people (who pay more) and those with lower incomes. Under the Senate bill, if someone goes without insurance for more than 63 days, they would have to wait six months to purchase new coverage on the individual market.

Protections for people with pre-existing conditions (that range from acne and mild allergies to cancer, asthma and diabetes) disappear under the legislation. Under the Senate bill, insurance companies could sell plans that don’t include the ACA’s essential health benefits if they also offer plan with those benefits on the exchange. There is some funding to help insurers who see sicker people sign up, but analysts and insurers warn that that offering two kinds of policies will create two markets, one for sick people who need more benefits and one for healthy people who need fewer. That would drive the cost of insurance much higher for people who want more benefits, including people with pre-existing conditions. Furthermore, state can change what defines an essential health benefit. Right now, those benefits include covering mental health treatment, prescription drugs, maternity care, addiction treatment and inpatient hospital stays. In a plan that does not have to be ACA compliant, insurers could opt not to offer those benefits or to charge more for them. This story out of Pennsylvania explains why this is now an issue. This story out of Missouri shows what changes might mean for one young man and many more like him. The House legislation would allow states to ask the federal government for permission to charge people more if they are sick if the state allocates some funding for high-risk pools. High-risk pools are a way to separate sick people from healthy people in the insurance market. Many states had them before the ACA. Maine's high-risk pool was viewed as successful because it was funded well — way beyond what the House bill allocates for them. Missouri's was not so well-funded, and most people could not afford to pay the premiums to join.

The GOP legislation would put financial burdens on 55- to 64-year-olds, who tend to have more pre-existing conditions such as cancer, diabetes and heart disease. If either of the bills becomes law, older people could be charged five times as much as a younger person for insurance. Right now, they can only be charged three times as much. People in this age group would also see their subsidies to help pay for insurance decline and could be more affected by loss of coverage for pre-existing conditions.

Hospitals are likely to face severe funding cuts, even with the restoration of some funds they lost under the Affordable Care Act. Hospitals in rural areas would be hit especially hard because they're highly dependent on Medicaid. Here are reports from Colorado, West Virginia, Kansas, Georgia, Missouri and California. Many other hospital systems, including in Connecticut, are bracing for bad news.

A one-year block would be placed on federal reimbursements for any care provided by Planned Parenthood. The Congressional Budget Office estimates that 15 percent of women who are low-income and don't have access to many health care options would lose access to family planning care entirely. This would increase birthrates and Medicaid spending for childbirth and children’s insurance. The Senate bill would implement restrictions on using tax credits to buy insurance plans that cover abortions, except in the case of rape or incest or when a pregnancy puts the mother's life in danger. The restrictions would go into effect in January 2018. One Connecticut professor warns that women's health care would be deeply affected and that the proposed changes could be damaging for women and children.

Although the Senate bill does increase the number of inpatient beds for psychiatric care, the deep cuts to Medicaid proposed in the same bill would severly reduce access to care for many with mental health problems. For people in Medicaid or on the exchanges, the regulations surrounding the Affordable Care Act's essential health benefits are loosened, so while insurers will have to offer an ACA-compliant plan on the exchanges, they will also be allowed to offer plans that don't have all the essential health benefits. This could mean prices for people who want more coverage for illnesses like depression could go way up.

These centers often help lower-income people. Leaders of four clinics from different parts of the country — Los Angeles, Phoenix, Denver and Rochester, N.Y. — talked about how their finances had changed under the Affordable Care Act and how a repeal may affect them.

On the one hand, 18- to 34-year-olds may see some premium relief. On the other hand, millennials fall into many categories, such as this man with a serious chronic illness who lives in Kansas.

The bill would repeal Affordable Care Act taxes on corporations and would cut some taxes for the wealthy. The cuts in the Senate's first version would add up to about $563 billion in tax cuts over 10 years, according to the Congressional Budget Office. Nearly 45 percent of those benefits will go back to the top 1 percent of earners. In January 2020, the bill would also repeal a tax charged to employers on employee health insurance premiums and benefits. The CBO will soon update its score for the new bill, introduced on July 13, 2017.

Both the state and the federal government pay for Medicaid, and under both GOP bills, the federal contribution would go way down over the next 10 years and beyond. States would have to make tough decisions, including considering limits on who is eligible for that funding, reductions in services covered or limits on what they pay providers and insurance companies. Many states — Connecticut, New York, West Virginia, New Jersey, Oregon, California (including rural areas of the state), Missouri, Indiana, Texas, Kentucky, Massachusetts, and Arizona — are bracing for the change. As are many groups covered by Medicaid: seniors, even those on Medicare, people with disabilities, veterans and children.

NPR's Alison Kodjak has this look at who and what Medicaid covers. Member station WNYC broke down its impact in New York and New Jersey.

The Affordable Care Act put a cap on how much consumers can be required to pay out of pocket in deductibles, copays and coinsurance every year. In 2017, it is $7,150 for an individual plan and $14,300 for family coverage. Yet there's a catch: The spending limits apply only to services considered essential health benefits. Both House and Senate bills weaken rules governing what those essential health benefits could include, and the out-of-pocket caps would not apply if a benefit were no longer deemed essential (such is the case of vision or dental insurance now).

The ACA prohibits insurers from limiting how much they would pay for expensive patients, a rule that is also tied to the essential health benefits. The GOP loosens restrictions on the requirements around plans providing the ten essential health benefits, so that cap might not cover those benefits a state deems not essential. If a benefit is not essential, an insurer could reinstate lifetime limits. One North Carolina couple frets about how this might affect their daughter.

Medicaid cuts could affect people's access to treatment. Three stories offer different perspectives: how one Pennsylvania woman got treatment thanks to Medicaid, which senators have a lot at stake, and how addiction treatment for pregnant women is critical in Kentucky. Medicaid spending on addiction medicine skyrocketed in the past five years, with the biggest increases in Medicaid expansion states.

People in rural areas could be disproportionately hurt by the GOP plans. They face particularly unstable insurance markets, according to the Congressional Budget Office. Smaller populations plus smaller subsidies could lead to fewer people buying individual insurance coverage in these areas, making exchanges less profitable. Some rural areas already face this problem under the Affordable Care Act. In addition, rural areas would be disproportionately affected by cuts to Medicaid.

There are about 22 million veterans in the U.S., and less than half get their health care through the Veterans Affairs system. Many vets instead rely on Medicaid for their health insurance. The GOP health care bill working its way through the Senate would dramatically reduce federal funding for Medicaid, so benefits for veterans would depend on how states cope with the cuts.

The GOP bill doesn't change the Affordable Care Act policy that gave women access to free contraception or that declared maternity and contraception "mandatory benefits" under Medicaid, but women could still lose birth control coverage if they are removed from Medicaid. Also, the states may have a lot of leeway to change what is mandatory. And employers with religious or moral objections can decline to provide insurance that covers birth control, per the Hobby Lobby case that was decided by the U.S. Supreme Court in 2014.

The idea is that people on Medicaid who are not disabled should work or be looking for work before receiving the benefit. Montana instituted an optional version of this when the federal government denied its request to make the rule mandatory.

NPR and its member stations have talked to people across the country. Check out these stories from New York, North Carolina, Pennsylvania, West Virginia, Kansas, rural Missouri and the St. Louis area, California, Connecticut, Arizona, Georgia, Texas, Minnesota and Colorado.

Two large health insurance industry groups, American's Health Insurance Plans and the BlueCross BlueShield Association, have called the Senate bill's provision allowing the sale of skimpier plans "simply unworkable in any form" and said that it would mean prices go up and millions of people who buy on the individual market will lose insurance. One large insurer, Anthem, came out in favor of parts of the House bill while others expressed reservations.

The health care sector saw growth under the Affordable Care Act. Here are stories out of Montana and Ohio. In the latter state, hospitals and local officials worry that cuts in health care spending will torpedo the job market. Medical device companies in Connecticut also are watching the bill closely, as they look forward to a tax repeal.

The Senate bill would continue allowing people up to age 26 to stay on their parents' insurance plans — a provision of the Affordable Care Act.

A revision to the Senate bill in late June added a provision that says people who have gone without coverage for more than 63 days in the past year have to wait six months before buying a policy. The House bill says people who go for 63 days without coverage must pay a 30 percent surcharge when they do buy a policy. Most experts predict these provisions would sink the insurance market because the incentives are not strong enough for people to keep coverage, so they would only buy when they had health needs such as a new cancer diagnosis. With only sick people buying insurance, costs would rise.

The Senate bill would repeal the limits on flexible spending account contributions and repeal the tax on medical devices, effective January 2018. The Senate bill would also let consumers use these accounts to pay health insurance premiums.

The Senate bill would implement restrictions on using tax credits to buy insurance plans that cover abortions and would ban the use of federal funds for any insurance that covers abortion, except in cases of rape or incest, or when the pregnancy puts the mother's life in danger. The restrictions would go into effect in January 2018.

Medicaid pays the costs for about 62 percent of seniors in nursing homes, and those people could be affected by cuts in Medicaid as federal payments to states decline (see chart here). In Alabama, for example, the bill could cost the average nursing home about $200,000 a year in revenue, a burden that could shut the facility down and leave people without care because 67 percent of nursing home residents in the state are covered by Medicaid.

As of January 2021 , eight states could lose Medicaid expansion funding if the federal matching rate dips below the rates the Affordable Care Act promises. Affected states are Arkansas, Illinois, Indiana, Michigan, Montana, New Hampshire, New Mexico and Washington. It's unclear whether the trigger would start when the law would go into effect or when the subsidies fall below promised levels.

The Urban Institute estimates that the number of uninsured people in West Virginia, Kentucky and Arkansas would rise by 200 percent or more.

The Affordable Care Act increased coverage to people with HIV through Medicaid expansion. It also requires coverage of essential health benefits including mental health services, maternity care and prescription drug coverage. The Senate bill would reverse Medicaid expansion and let states waive coverage of essential health benefits.

The Senate bill could significantly alter coverage for people who get insurance through their employers. The bill would allow states to opt out of some Affordable Care Act mandates such as required coverage of 10 essential health benefits, which include hospitalization, medications and maternity care. While employer plans do not have to abide by those rules, the ACA does bar employer plans from placing a lifetime limit on coverage for those benefits.