The law has 2 parts: the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act. You can view them in PDF or HTML. American Health Care Act of (as reported) Amendment #32 offered by the Hon. Gary Palmer (AL) and David Schweikert (AZ) PDF —The amendment. H.R. The American Health Care Act (AHCA) portal7.info th-congress/costestimate/portal7.info
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This Act may be cited as the ''American Health Care. 4. Act of ''. 5. SEC. 2. TABLE OF CONTENTS. 6. The table of contents of this Act is as. This Act may be cited as the ''American Health Care. 2. Act of ''. 3 Repeal of the tax on employee health insurance premiums and health. Subtitle C—Quality Health Insurance Coverage for All Americans .. Amendments to the Public Health Service Act, the Social Security Act, and title V of this Act.
Background[ edit ] The ACA colloquially called "Obamacare" , a major reform of health care in the United States , was passed in by the th Congress and signed by President Barack Obama in after nearly a year of bipartisan debate. During the presidential election , Republican nominee Mitt Romney , running against Obama, promised to repeal the ACA, despite its similarity to Romneycare. In the th Congress , Republicans passed a bill that would have repealed much of the ACA, but the bill was vetoed by President Obama. States would be allowed more flexibility in establishing essential health benefits i. Provide funding to health insurers to stabilize premiums and promote marketplace participation, via a "Long-Term State Stability and Innovation Program" with features analogous to a high-risk pool.
Reduce Medicaid payments relative to current law, by capping the growth in per-enrollee payments for non-disabled children and non-disabled adults, by using a lower inflation index. Allow insurers to charge premiums up to five times as much to older people vs. Remove federal cap on the share of premiums that may go to insurers' administrative costs and profits the "minimum medical loss ratio". Views were split along party lines.
Cuts to Medicaid more than offset tax cuts, resulting in moderate deficit reduction. Other groups have evaluated some of these elements, as well as the distributional impact of the tax changes by income level and impact on job creation.
The results of these analyses are as follows: Health insurance coverage[ edit ] According to each of the CBO scores, passage of the Republican bills would result in a dramatic reduction in the number of persons with health insurance, relative to current law.
In , most of the reduction would be caused by the elimination of the penalties for the individual mandate, both directly and indirectly. Later reductions would be due to reductions in Medicaid enrollment, elimination of the individual mandate penalty, subsidy reduction, and higher costs for some persons.
By , an estimated 49 million people would be uninsured under the Senate BCRA, versus 28 million under current law. Medicaid spending would be cut considerably.
Regarding quality, the "actuarial value" is an estimate of the percentage of total cost that a particular insurance plan is expected to cover. CBO reported that: CBO AHCA March Insurance premiums would rise initially relative to current law, but would be reduced in the future moderately: "Starting in , the increase in average premiums from repealing the individual mandate penalties would be more than offset by the combination of several factors that would decrease those premiums: grants to states from the Patient and State Stability Fund which CBO and JCT expect to largely be used by states to limit the costs to insurers of enrollees with very high claims ; the elimination of the requirement for insurers to offer plans covering certain percentages of the cost of covered benefits; and a younger mix of enrollees.
By , average premiums for single policyholders in the nongroup market under the legislation would be roughly 10 percent lower than under current law A combination of factors would lead to that decrease—most important, the smaller share of benefits paid for by the benchmark plans and federal funds provided to directly reduce premiums.
That share of services covered by insurance would be smaller because the benchmark plan under this legislation would have an actuarial value of 58 percent beginning in That value is slightly below the actuarial value of 60 percent for "bronze" plans currently offered in the marketplaces.
The deductible for a plan with an actuarial value of 58 percent would be a significantly higher percentage of income—also making such a plan unattractive, but for a different reason. As a result, despite being eligible for premium tax credits, few low-income people would download any plan For that person, silver plans would be basically identical in terms of cost and quality.
Relative to current law, persons aged 64 years old would pay considerably more for either a bronze or silver plan under BCRA, while a 21 year old would pay considerably less under BCRA, due in part to relaxing the rules on how much more older persons can be charged relative to younger.
The ACA also established a penalty tax related to the individual mandate for individuals without adequate insurance, an excise tax on employers with 50 or more workers who offer insufficient coverage, annual fees on health insurance providers, and the "Cadillac tax" yet to be implemented as of on generous employer-sponsored health plans.
Combined with subsidies that primarily benefit low-income households, the law significantly reduced income inequality after taxes and transfers.
The effects overall would worsen income inequality. It is the primary payer of nursing home care. In states such as California, where nearly one in four undocumented individuals lives, this population comprises a large share about one-third in and projected to increase to almost half by of the remaining uninsured 30 , Given this gap in care, five states California, New York, Illinois, Washington, Massachusetts and the District of Columbia have extended coverage to low-income undocumented immigrant children, and proposed legislation in California Senate Bill 10 would allow undocumented adults to download coverage through the state exchange.
Though policies in select states have opened pathways to coverage, a substantial number of undocumented immigrants will continue to remain uninsured, and health care safety nets such as community health centers and Emergency Medicaid and Disproportionate Share Hospital programs will continue to play an integral role in providing care for this vulnerable population 1 , 71 , 73 , In summary, early evidence following ACA implementation has demonstrated significant progress toward its goal of expanding coverage for millions of low-income individuals who would have otherwise remained uninsured.
Not all individuals equally experience the potential benefits of the law, however, and disparities have developed on the basis of state decisions regarding whether to expand Medicaid.
Implications of Expansions Prior to ACA Implementation Given passage of minimal time since the ACA was implemented, examination of pre-ACA coverage expansions may provide insight into the anticipated effect of the law on access to care. Pre-ACA insurance expansions have largely demonstrated improved access to care for low-income populations.
For example, the Massachusetts health reform was associated with significant reductions in forgone or delayed care and improvements in access to a personal doctor and usual source of care among adults overall 46 , 54 , 56 , 58 , 72 , 88 and, in particular, for subgroups targeted by the ACA, such as low-income and childless adults 54 , 56 , With regard to affordability, the Medicaid expansion in Oregon diminished financial hardship from medical costs, markedly reducing catastrophic OOP expenditures 5 , 35 , In addition, other states that expanded public insurance prior to the ACA demonstrated improvements in access and affordability among low-income adults 62 , 82 and children 33 , 44 across comparable measures.
More recently, the California LIHP waiver project found large reductions in the likelihood of any family OOP health care spending but did not detect significant differences in access to care, which may be explained by a well-established safety net in the state prior to program implementation One ongoing concern about expanding coverage is that increased demand for services by newly insured individuals may limit access to care, but evidence from prior expansions does not appear to sufficiently support this hypothesis Among nonelderly adults overall, the ACA has been associated with improvements in having a usual source of care and greater ease in accessing medications and with reductions in delaying or forgoing necessary care 19 , 79 , Benefits have also extended to low-income adults in particular, who have shown similar improvements in access to a doctor 84 , 85 , 92 and usual source of care 7 , 79 , 84 , 85 , largely attributed to Medicaid expansion.
As expansion decisions and mechanisms continue to be debated politically in certain states, it merits highlighting evidence suggesting that different expansion approaches i. Because cost is a well-documented barrier to access and disproportionately burdens low-income populations, assessments of affordability remain critically important.
Adults who gained coverage through the ACA have provided favorable reports of affordability 24 , 26 , 74 , likely due to cost-sharing protections of ACA provisions. Similarly, problems with cost-related unmet need or skipped medications, paying for medical bills, and annual OOP spending have been significantly reduced among low-income adults in Medicaid expansion states compared with nonexpansion states 7 , 80 , 83 , Early evaluations of ACA impacts, however, have not uniformly documented improvements in access and affordability across all outcomes, and challenges persist 79 , 83 , 85 , In the year following Medicaid expansion, a study found no significant changes in having a usual source of care and in affordability measures such as cost-related delays in medical care, unmet medical care, and lack of a usual source of care among low-income nonelderly adults Others have similarly found positive but nonsignificant improvements in ease of obtaining primary and specialty care appointments and ability to afford care among the poor in Medicaid expansion states compared with nonexpansion states 83 , 84 , For individuals seeking care in the Marketplace, inadequate access to in-network specialty care and incurrence of high OOP costs also remain a concern The potential impact of narrow networks and consequences of selecting plans with high deductibles or copayments require further investigation.
Overall, nonelderly adults who experience access problems e. Encouraging research, however, suggests that the ACA has reduced some income and ethnic disparities in access to care 19 , In summary, consistent with studies of previous expansions, research examining the early impact of the ACA suggests improvements across a variety of dimensions of access and affordability.
By reducing these barriers, the ACA is expected to encourage the use of needed services that prevent or improve health conditions and subsequently reduce the use of other less efficient services. Impacts of Pre-ACA Expansions With such limited empirical data to address the impact of the ACA on utilization, evaluations of recent pre-ACA health insurance expansions can be helpful in predicting longer-term effects of the law.
Results from the OHIE and Massachusetts reform, as well as other state Medicaid expansions, consistently show a significant increase in outpatient utilization e. For inpatient utilization [i. For example, some OHIE studies using administrative data found a significant increase in ER visits and the probability of hospital admissions among new Medicaid enrollees following the expansion in Oregon 34 , 35 , 91 , whereas another analysis of self-reported data did not reveal any changes 5.
Findings regarding inpatient utilization were similarly mixed among studies that evaluated a public insurance expansion for low-income childless adults in Wisconsin 15 , These inconsistencies for inpatient outcomes across evaluations of pre-ACA reforms may be driven by several factors including different methodological approaches, data sources, and follow-up time examined; state policies targeting poor populations prior to the expansion; regional variation patterns in care delivery; and unique features and implementation of individual state Medicaid programs.
Following implementation of major provisions in , significant increases in outpatient utilization and preventive care have been observed 3 , 19 , 79 , 80 , 84 , 85 , After one year, there was a significant increase in the probability of having a physician visit and routine check-up among nonelderly adults overall 19 , Medicaid expansion, in particular, has been associated with a significant increase 6.
Consistent with these national findings, a comparison of two states Arkansas and Kentucky after the first two years of expansion to one nonexpansion state Texas found increases in outpatient office visits and use of preventive care services such as check-ups, regular care for chronic conditions, and glucose checks among those with diabetes Thus, early findings suggest that, similar to pre-ACA reforms, the ACA has encouraged the use of outpatient services and preventive care among low-income individuals.
For inpatient utilization, however, findings have varied over time and by population 19 , 83 , 84 , In the year following implementation of the ACA, there were no changes in ER visits among nonelderly adults overall Early research on Medicaid expansion, in particular, found no change in ER visits within the first year among low-income adults 83 , 97 , though one study revealed a significant increase 7 percentage points in ER visits after excluding young adults who may have benefited from the dependent coverage provision Studies assessing longer follow-up times, however, underscore how the effects of the law may evolve over time 83 , For example, evaluations of Medicaid expansion in three southern states initially found no changes in ER visits after the first year of expansion 83 but subsequently identified reductions in the likelihood of an ER visit and, importantly, reliance on the ER as usual care by the second year Future evaluations of the ACA should continue to examine mechanisms of utilization among low-income individuals.
First, it will be important to understand how the ACA affects the complex relationship between utilization in the outpatient and inpatient settings, namely whether increased use of outpatient services potentially induces inpatient care as observed in the OHIE or, alternatively, substitutes for inpatient care and reduces preventable ER visits e.
Individuals who were previously uninsured may have forgone or postponed necessary care because of financial constraints, and expanded insurance coverage under the ACA may increase utilization that could overwhelm both the health care system and state budgets.
Thus, based on pre-ACA expansions, long-term patterns of use among low-income, newly insured individuals remain uncertain. Health has often been assessed across dimensions of self-reported general and mental health, diagnosed chronic conditions, clinical indicators, and mortality. Many have taken advantage of natural experiments to overcome the endogeneity challenge presented when examining the causal relationship between gaining health insurance and experiencing better health Improvements in self-reported health were observed among nonelderly adults following the Massachusetts reform 88 , as well as among low-income adults who gained Medicaid coverage following expansions in Oregon, New York, Maine, and Arizona 5 , 35 , Although significant changes in mortality were not detected in the OHIE after one year 35 , the other coverage expansions, which were evaluated over a longer period of time, provide compelling evidence that mortality declined among low-income adults 82 , In addition to self-reported health and mortality, clinical outcomes were evaluated in the two years following the OHIE.
Whereas no significant changes were observed for clinical outcomes determined to be sensitive to changes within this time period, such as blood pressure, cholesterol level, or hemoglobin level, a higher probability of diagnosed diabetes and a substantial decrease in probability of depression were found among those who received Medicaid coverage 5.
Despite potential limitations of these studies e. After one year, an improvement in self-reported health was found among nonelderly adults overall Medicaid expansion, in particular, was not associated with significant changes in self-reported health among low-income adults after one year 83 , 85 , 97 , but improvements were observed after two years 80 , 84 , most substantially among low-income childless adults, an important subgroup who benefited from expanded Medicaid eligibility Early evaluations of Medicaid expansion have also revealed no associations with changes in rates of self-reported or positive screening results for depression, diagnosed hypertension, or health behaviors such as obesity, but have observed significant increases in rates of diagnosed diabetes and high cholesterol 43 , 80 , 83 , 84 , Overall, these findings further lend evidence to the potential benefits of Medicaid expansion, regardless of expansion approach, and to the notion that health impacts may take more time to materialize.
Researchers have hypothesized that lack of immediate improvements in perceived health status could be explained by increased awareness of newly diagnosed conditions, though these perceptions may improve over time as conditions are treated 47 , 94 , In addition, it will be important to monitor possible reductions in health disparities under the ACA.
In a previous study of uninsured adults in the years leading up to Medicare eligibility, health trends were significantly worse and worsening faster for uninsured individuals compared with insured individuals. After gaining Medicare coverage, however, the health status of the previously uninsured improved to levels comparable to the insured These findings suggest that, by extending coverage to the previously uninsured, the ACA may play a significant role in reducing health disparities experienced by the previously uninsured.
Low-income individuals who are eligible for benefits continue to be uninsured because of ongoing affordability concerns, either because they live in a state that refuses to expand its Medicaid program despite the availability of substantial federal funding or because they are undocumented and prohibited from ACA benefits.
Nevertheless, the early evidence strongly indicates that the ACA is working; it has substantially reduced the number of uninsured and has improved access to coverage for 20 million newly insured people. Over the longer term, further research may show improvements in self-reported health status and better mental and physical health outcomes not only from better access to care, but also from significant reductions in financial stress for low-income individuals and families. There are limitations to the recent evaluations of the ACA.
First, most assessed limited follow-up time, with some relying on only 6 to 12 months of post-ACA data. It will likely take longer for the effects of the law to become evident. Second, although some of these studies methodologically took advantage of some states choosing to expand Medicaid while others did not i. Thus, the observational studies are susceptible to unmeasured confounders, particularly those that may differentially change over time in expansion versus nonexpansion states.
Finally, implementation of Medicaid expansion and the ACA more broadly is not homogenous across states, which could impact eligibility for coverage as well as access, utilization, and health outcomes. Although steps were taken to mitigate these limitations, future evaluations will need to continue to monitor the impact of the ACA across these domains to fully understand its impact on low-income populations.
Insurance coverage among Americans has significantly increased since ACA implementation, especially those in Medicaid expansion states and among subpopulations targeted by the law, namely the poor, childless adults, ethnic minorities, and young adults. As undocumented residents do not qualify for assistance under the ACA, the remaining uninsured also include about 5. The ACA has generally been associated with significant improvements in access and affordability and increases in outpatient utilization among low-income populations, but changes in inpatient utilization and health outcomes have been less conclusive.
Despite the availability of subsidies and cost-sharing reductions, the reliance of the ACA on health insurance exchanges might increase access to health insurance, but simultaneously pose unintended barriers to access through creation of narrow networks and existence of high-deductible Bronze plans.
A major limitation of post-ACA evaluations is minimal follow-up time, as it will likely take longer for the effects of the law to materialize. Therefore, continued monitoring of implementation and effectiveness is essential.
Agabin N, Coffin J. J Med Pract Manag.
An early look at rates of uninsured safety net clinic visits after the Affordable Care Act.