The fact that sick people could be charged more for health insurance is one of the provisions of the Republican Party’s plan to overhaul the Affordable Care Act that has sparked the most controversy.

Now there are numbers that suggest that almost half of all Americans would be affected in some way by the GOP plan. And the state you call home could determine whether you are among them.

The Congressional Budget Office’s analysis of House Republicans’ American Health Care Act, released Wednesday, looked at the effect of a last-minute amendment to the AHCA that lets states waive two key ACA requirements: one that prohibits insurers from charging sick people more than healthy people if they have a break in insurance coverage and another that requires insurers to offer policies with 10 “essential” health benefits, such as maternity care, mental healthcare, and prescription drug coverage.

The CBO estimates that about 88 million people—or one in three younger than 65—live in states that are likely to waive the 10 mandated health benefits, allowing people to buy cheaper policies but with less coverage.

The analysis also estimates that 44 million people—one in six of us—live in states that could waive both requirements, allowing less comprehensive coverage and more expensive policies for sick people.

As a result of these AHCA changes, the CBO believes that by 2026 there would be 51 million Americans who wouldn’t have health insurance—either by choice or because they couldn’t afford it—compared with 28 million who would be without coverage if the ACA stayed in place.  

House Speaker Paul Ryan, R-Wis., disputes the CBO’s analysis. He and other Republicans say the waivers wouldn’t hurt people with pre-existing health conditions because the AHCA also provides funding to create high-risk pools where sick people can get insurance.

“We just think it’s a lot smarter to directly subsidize the care for people with catastrophic illnesses,” Ryan told reporters Thursday.

But the CBO report casts doubt on that, saying that the funds provided to states—about $138 billion over 10 years—would not be enough to protect sick people from huge bills and that some people would not be able to affordable coverage at all. Many health policy experts agree.

“People who are less healthy or who need expensive care would essentially be priced out of the market over time if they live in one of these states,” says Sara Collins, vice president of healthcare coverage and access at the Commonwealth Fund, a foundation that does independent research on health and social issues.

 

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Identifying the Danger Zones

Assessing how many states would apply for one or both waivers was a tricky job for the CBO. They had to look at states’ past behavior and current market challenges. Although the CBO report didn’t name the states that it suspects will opt for waivers, the guidelines it used shed some light on which ones are more likely to. Waivers may be more likely to be applied for by:

• States with a track record of loose regulations. Before the ACA, there was a wide variation in what states required insurers to cover. Only 18 states, including California, New York, and Colorado, mandated that insurers provide maternity care before 2014, and 23 required some mental health benefits, according to the Kaiser Family Foundation. Just seven states banned pricing insurance on a person’s health status. States that previously mandated fewer benefits would be more likely to waive essential health benefits, according to the CBO. For a full list you can check Kaiser’s State Health Facts tool, which allows you to identify state coverage requirements pre-ACA.

• States with high premiums. In 2017, the average insurance premium on the most popular Silver plan on ACA exchanges was 17 percent higher than the year before, according to HealthPocket, a company that analyzes health plans. But in some places the increase was even sharper. In Arizona and Oklahoma, for example, premiums shot up more than 50 percent.

For the 2018 market, some insurers have already filed requests for steep rate hikes. For example, CareFirst, a Blue Cross Blue Shield company, asked for an average 52 percent increase in rates in Maryland and 35 percent in northern Virginia, according to Healthinsurance.org.

• States with few insurers in the marketplace. One-third of counties in the U.S. have only one insurer on their exchange, according to the Kaiser Family Foundation. States struggling to attract or retain insurers, such as Oklahoma and Iowa, whose sole insurers have recently warned them they’re likely to pull out, would be more likely to seek waivers.

If the AHCA does become law, states could apply for waivers that kick in as soon as 2018. But because implementation would probably take longer, people might not see changes until 2020, says Timothy Jost, a health policy expert and professor emeritus at Washington and Lee University School of Law.

And it’s possible that even more people would be affected than the CBO projects. The CBO itself said its analysis was a moderate estimate. More states could apply for waivers if premiums continue rising or states find that insuring sick people gets too costly. “If the waiver program works in states that embrace it, as Republicans predict, there might be pressure on additional states to seek waivers,” Jost says.