The Senate GOP legislation to replace the Affordable Care Act appears all but dead for now, but Republican efforts to repeal the law are not, injecting even more uncertainty about the future of health insurance into an already shaky market.

That uncertainty poses immediate threats as consumers—and insurance companies—are left lingering in healthcare limbo.

The confusion over whether the ACA ultimately survives means “some people will have fewer choices, higher premiums, and bigger out-of-pocket costs," says Chris Sloan, a senior manager at Avalere Health, a healthcare consulting firm.

And the longer uncertainty about healthcare reform lasts, the bigger the impact on consumers, he says.

Here's how you could feel the pain:

Fewer Plans to Choose From

One of the key areas of uncertainty centers on subsidies that, under the ACA, help consumers cover out-of-pocket costs such as deductibles and co-pays for office visits and prescription drugs.

Under the current system, insurance companies cover those costs upfront, then get reimbursed by the federal government—to the tune of about $7 billion per year.

Insurance companies depend on those reimbursements—called cost-sharing reductions, or CSRs—saying that without them they can't make money on the plans they sell through the ACA exchanges.

President Donald Trump wants the Senate to repeal the ACA and deal with a replacement later. In the meantime, the Trump administration has agreed to reimburse insurers for those expenses only on a month-by-month basis. And without long-term assurance, many insurers say that continuing to offer ACA plans is too financially risky, prompting many to say they may have to drop out.

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Some have already done just that.

The Centers for Medicare & Medicaid Services last week reported that the number of insurers applying to take part in health insurance exchanges in 2018 dropped to 141, down from 227 this year—a 38 percent decline.

Currently, 38 out of 3,143 counties in the U.S. are at risk of having no insurers offering plans on the 2018 marketplace exchanges, according to the Kaiser Family Foundation. A recent Avalere analysis found that 41 percent of counties might have only one insurance option in 2018.

Not all insurers are scared off. A few, such as Centene and Oscar Health, say they are expanding into new markets. 

But if you live in an area that has no insurer offering ACA plans, your only option to buy insurance is off-exchange. Those plans tend to cost you more, because you won't be eligible for either subsidies that help cover your out-of-pocket costs or reduce your premiums, says Christine Eibner, a senior economist at Rand, a nonpartisan public policy research organization.

Higher Premiums

The uncertainty about CSR reimbursement also means that insurers that do offer plans for 2018 will probably charge higher premiums.

For example, Blue Cross and Blue Shield of North Carolina is asking for a 22 percent increase in premiums but said if CSRs were funded, it would need to raise rates only 8.8 percent.

Overall, among the companies whose rate increase proposals for 2018 plans are public so far, insurers are asking to boost premiums an average 34 percent, according to Charles Gaba, who is tracking the rate filing data at ACAsignups.net.  

While those are steep increases, it's important to note that under the ACA, most consumers—about 85 percent—receive substantial subsidies that help defray the costs of their premiums, Eibner says.

If Senate repeal efforts are ultimately successful, those subsidies would go away so the premium increases being implemented now would be even more painful down the road.


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More People Without Insurance

Under the ACA, if you don't get insurance from your employer, Medicare, or Medicaid, you have to buy it on your own—or pay a penalty, the so-called "individual mandate."  

While the Trump administration is pushing for a quick repeal of the ACA, it has already signaled that even if efforts to repeal the ACA fail, it might not strictly enforce the penalty in the meantime. The prospect of greater leniency could prompt some people to forgo signing up for insurance. If the penalty isn't enforced, healthier people are more likely to choose not to have insurance and that would drive costs higher for everyone who wants insurance, Sloan says.

Evidence that this may be happening comes from a recent Gallup-Sharecare survey, which showed that the percentage of Americans without health insurance rose to 11.7 percent in the second quarter of 2017, up from 10.9 percent at the end of 2016.

Though that's still well below the uninsurance rate before the ACA—which reached 18 percent in 2013—it's still a significant increase, according to the Gallup-Sharecare survey, equivalent to about 2 million more people without insurance.

Other factors could also be contributing to the bump up in uninsured people, including the fact that the Trump Administration also has curtailed ACA outreach efforts designed to encourage enrollment.

And, of course, some people may have dropped out simply because they couldn't afford insurance in the face of the stiff premium increases of the last few years.

States Take Action on Their Own

As efforts in Washington stall, some states are moving ahead with their own plans to shore up their insurance markets, which could help consumers.

Last week, Alaska got a waiver from the feds to create a reinsurance program that could help lower ACA premiums in that state—which are the highest in the nation—by 20 percent, according to the Department of Health and Human Services. The reinsurance program would direct some federal money to the state, which it can use it to offset the cost of insuring people with high-cost medical conditions.

Officials in Iowa, Minnesota, New Hampshire, and Oregon have said they are considering similar programs, according to HHS.