michelle ko md phd

social determinants + healthcare = disparities

Healthcare reform repeal replace: What now?



Still having trouble figuring out what just happened? And what happens now?

To recap: The Senate failed to pass several bills for repeal and replace, or just replace, the Affordable Care Act.

What to watch now:

  1. The Administration may continue to attempt to undermine the individual health insurance markets by refusing to pay cost-sharing reductions (CSRs). CSR’s are payments that help low-income people pay for their co-payments, deductibles, and co-insurance: many items that add up to out-of-pocket costs.  Without this assistance, it would be hard to afford healthcare services even if the premiums are low. Without CSR’s, (healthy) people would likely drop out of the individual insurance market and costs will get higher for everyone else who stays in. In other words, this is a way in which Administration policy can still dismantle pieces of the Affordable Care Act without an act of Congress.  Of note, the Administration is continuing what came out of an act of Congress….Republicans sued the Obama Administration in 2014 over CSRs (one of many aspects in which the ACA was challenged from being fully implemented). You can read the Vox summary for more on CSR’s.
  2. Bipartisanship? : The House Problem Solvers Caucus has come up with a bipartisan plan with various fixes to current ACA problems.
  3. Even Bigger Block Grants: Sens. Graham and Cassidy propose to take all the money available under the ACA and give to states as one big block grant– even bigger than the Medicaid block grant, this would include premium subsidies, CSRs, and Medicaid expansion.  Concerns about block grants posted last time.

Click here for a handy timeline of key events coming up in healthcare policy.

BCRA Drill-down: Medicaid Block Grants

Both BCRA and AHCA would allow states to receive Medicaid funds in the form of a block grant- this would enable states to construct their programs and funding to fit the needs and priorities of their residents, rather than be subject to inflexible federal rules that may make no sense across different contexts.

Sounds good, right? Not so fast. On the Health Affairs blog, Prof. Marianne Bitler and I argue that the history of welfare reform shows it may not be that easy.

The Better Care Reconciliation Act: The Senate throw-down to the AHCA

How many acronyms were up there? (A few) Senate Republicans released their draft response to the House American Health Care Act, the Better Care Reconciliation Act.  There is much more detail in BCRA, and yet the upshot seems to be that BCRA ups the ante from the AHCA on disparities, again favoring the younger, healthier and wealthier vs. the poorer, sicker, and older.

Others have written excellent summaries of the BCRA overall, as well as specific review of changes to Medicaid not related to caps,  So I won’t waste your time or mine.

A couple points-

  1. Immigrants: There’s a small distinction which appears to restrict premium tax credits from a subset of immigrants, all of whom are Lawfully Present (allowed to stay in US)  but now limited to Qualified Aliens vs. Non-Qualified Aliens.  As a non-expert, Non-qualified is utterly confusing to me and all I have figured out so far is that those under DACA are Non-Qualified and therefore would not be eligible for tax credits to purchase health insurance.
  2. Elimination of the ACA Public Health and Prevention Fund: once again signaling how the U.S. simply does not prioritize public health.
  3. Tax cuts for the wealthy: Income inequality goes up–> Health disparities go up.
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