HARI SREENIVASAN: Let’s dive a little deeper into the bill passed by the house, what it would change when it comes to coverage and cost, and the politics moving forward.
Our own Lisa Desjardins joins us for that, just back from Capitol Hill. And Julie Rovner is with Kaiser Health News.
Lisa, let’s start with pre-existing conditions. That became the phrase that pays all week long and even today. Who is going to get left out of this?
LISA DESJARDINS: It is a very serious concern, according to Kaiser Family Foundation, as Julie talk more in a second, some 52 million Americans have pre-existing conditions, adults, and could have their insurance affected.
The way this works, Hari, is that each state would decide if they want a waiver so that their insurers could opt out of the preexisting protections, as they’re called. Now, Republicans say that this should not affect those with pre-existing conditions because if their premiums get too high, they’ve created what’s called high-risk pools. They say that will help them.
But I spent a lot of time talking to Republicans about this today. They do not guarantee that your premium won’t go up if you have pre-existing conditions. Insurers can raise those premiums. The question is, will states actually opt in to do this?
And also important, Hari, it’s easy to get these waivers under this particular version because if the state applies for it, if the government does nothing, it happens. The government has to actually block the waiver.
HARI SREENIVASAN: So, a lot of this seems to depend on a state-by-state basis on who decides to continue?
JULIE ROVNER, Kaiser Health News: Well, absolutely. You know, this is one of the things Republicans said. They don’t like that health care is being basically governed from the federal government. They want to turn it back to the states.
Now, we should say states already have a lot of power in the insurance market. They do — they still regulate individual insurance. They still regulate insurance for small businesses, insure — businesses that operate in multiple states are regulated by the federal government. But that wasn’t the Affordable Care Act. That’s been the case.
HARI SREENIVASAN: One of the things that the Republicans have said is, “one of our methods to deal with this is creating these high-risk pools.” Let’s talk about that. I mean, how would they work?
JULIE ROVNER: Well, basically, 35 states used to have these high-risk pools, and these are people who have very expensive conditions, with an ongoing — normally, an ongoing problem. And they basically get shunted off into a different pool, that’s why they’re called high-risk pools. And the reason is that the healthier people in the regular pool would then have lower premiums because they’re not paying for those expensive people.
HARI SREENIVASAN: But does that mean that the sicker people have higher premiums?
JULIE ROVNER: That’s exactly correct. The sicker people could get insurance but they had higher premiums. Sometimes they had pre-existing condition exclusions so you wouldn’t get coverage for the very thing that got you into the high-risk pool, sometimes for up to a year. And also, a lot of them were underfunded. So, they would close to new entrants. There was a pool in Florida that was closed for decades.
HARI SREENIVASAN: Lisa?
LISA DESJARDINS: And that’s where this money comes in that Republicans added at the last minute, another $8 billion that could go to the high-risk pools to try and help stabilize those premiums, but we have no idea if that’s enough money. There is not a CBO score on this bill. We don’t know — there is not a CBO score for how much is needed in that kind of national, potential high-risk pool. It’s a huge question mark. There are many people who say $8 billion is not going to cut it.
HARI SREENIVASAN: And we have tried to supplement these high-risk pools in the past few years, and it’s come up short.
JULIE ROVNER: There was a federal high risk pool in the transition to the Affordable Care Act, and it closed I think more than a year early because it ran out of money.
HARI SREENIVASAN: OK. Let’s talk a little bit about the essential health benefits. That’s also something that has been discussed, on something that could really strain the average household or the average family.
First, to set the table, what are some of the essential health benefits that have been guaranteed under the Affordable Care Act that are under threat now?
LISA DESJARDINS: It’s sort of an unseen skeleton of American health care. We’re talking about things like hospital care, being able to do to go to the hospital. Emergency care, the ER, maternity care, preventive care, that could be anything from cancer screenings to, right now, contraception, depending on how the health agency goes forward. It is — also, prescription drugs.
Ten basics that the Congress under Obamacare said must be in every plan. Now, the way Republicans in the House want it, they want states to be able to waive out of those essential benefits.
HARI SREENIVASAN: So, now, you’re creating a market on a state-by-state basis saying, I’m going to have an essential health package that’s different from my neighboring state, right?
So, this is one of the things Donald Trump confidently said today that, we’re going to drive down premiums. We’re going to drive down these costs. Is it likely that states will start to offer up these different packages for employers from other places?
JULIE ROVNER: Well, actually, already, states get to pick which — you know, which kind — they’re called a benchmark plan. It does have to have those benefits, but states can decide on a state-by-state basis what the plan should be modeled as.
What this is saying is that it would give insurers the ability to just jettison some of those benefits. Now, they probably wouldn’t jettison hospital care and doctor care. But they might, you know, say, we’re not going to cover maternity care. We’re not going to cover mental health care. We’re only going to cover generic prescription drugs and not brand name prescription drugs.
So, then, probably, premiums would go down, but people who needed that coverage wouldn’t have it anymore.
LISA DESJARDINS: But people would be making that choice, Republicans argue. They say you could choose to have a bare-bones plan.
HARI SREENIVASAN: Instead of a Cadillac plan.
LISA DESJARDINS: That’s right.
HARI SREENIVASAN: One the biggest numbers in this: $880 billion in cuts to Medicaid. How does that go forward?
JULIE ROVNER: This is really sort of the — has been hidden in the debate. This is a tremendous change to Medicaid. For the first time since Medicaid was created in 1965, there would no longer be open-ended federal funding. And we’re not just talking about the medication expansion that was in the Affordable Care Act. That would be phased out. We’re talking about the basic Medicaid program that pays for maternity care, child birth for almost half the children born in the United States and the majority of nursing home care.
So, that’s where the Congressional Budget Office suggested that much of the declining coverage would come from where states losing money for Medicaid.
HARI SREENIVASAN: And when you look at the politics of this, is there are senators and there are governors who are not in favor of this.
LISA DESJARDINS: That’s right. And I think we’re going to pay a lot more attention to the Senate now. They have a real problem in the Senate. In fact, you talk too some senators who have been around for a long time, including the chairman of the HELP Committee, the HELP Committee, as it’s called, Alexander, his office sent me an email tonight. He said the Senate is going to write its own bill. They’re going to start and go in their own direction.
Medicaid is a big problem. And states with some of the highest Medicaid rates are also states with Republican senators. They are taking that very seriously.
Also, Hari, today, nine of those Republicans who voted no on this bill had districts where Hillary Clinton won the presidential election. So, there are real issues for 2018 here.
HARI SREENIVASAN: One of the things that we’re also hearing today is that this could affect people who are not in need of the Affordable Care Act or a government plan, people who have private insurance through their employers, which is the bulk of the population.
JULIE ROVNER: That’s right. And, you know, this is a very good example of how complicated this all is. These things are tied to each other. And when you pull one piece of it out, you could inadvertently touch another piece. This is an example.
The Wall Street Journal this morning reported that people who have now — employers are required not to offer coverage that have lifetime limits that say once you have $1 million in claims, you can’t do it anymore, you can’t cover it anymore. It’s tied to those essential health benefits. So, if the essential health benefit goes away —
HARI SREENIVASAN: Yes.
JULIE ROVNER: — then, once again, employer coverage could have lifetime limits.
HARI SREENIVASAN: All right. Julie Rovner and Lisa Desjardins, thank you both.
LISA DESJARDINS: Thanks.
JULIE ROVNER: Thank you.
HARI SREENIVASAN: To help you keep track of the many details, we have a guide to the GOP health care bill on our website. That’s pbs.org/newshour.