Back in March, House Republicans pulled the unpopular and highly problematic American Health Care Act from consideration, and House Minority Leader Paul Ryan declared “Obamacare is the law of the land.” Now, however House Republicans are trying again to undo the Affordable Care Act. Last week, Representative Tom MacArthur (R-NJ) introduced an amendment designed to win over the hard-line House Freedom Caucus, who opposed the original AHCA because it didn’t do enough to roll back existing law.

As the New York Times’ Margot Sanger-Katz summarizes, the amendment would allow states to receive waivers to:

• Replace the essential health benefits standards with their own standards (e.g., to eliminate the requirement that insurers cover maternity benefits, prescription drugs, etc. — see Kim Krisberg’s post for more);
• Charge higher premiums to customers with high health needs who had experienced a lapse of coverage lasting more than 63 days (i.e., end community rating for those without continuous coverage); and
• Charge older people up to five times as much as younger people, instead of the ACA’s 3:1 limit (i.e., modify the ACA’s age rating provision).

Sanger-Katz explains: “Broadly speaking, states with such waivers would be worse for Americans with more complex health care needs, but would have lower insurance premiums for people without a history of illness.” Of course, many of us start our adult lives without a history of significant illness, but become more expensive to insurers as we age or bear children. So, someone getting a good deal under this version of the AHCA in 2018 could easily find premiums skyrocketing a few years later – a problem the Affordable Care Act was specifically designed to address.

States that receive waivers would have to set up high risk pools if they get a waiver that allows insurers to charge higher premiums to sicker customers, Sanger-Katz notes. When states set up high-risk pools in the past, though, many faced spiraling costs. Minnesota’s pre-ACA high-risk pool was widely considered one of the best, but MPRNews’s Mark Zdechlik reported that it needed large subsidies and still left many consumers facing costs that were far too high:

Craig Britton of Plymouth, Minn., once had a plan through the state’s high-risk pool. It cost him $18,000 a year in premiums.

Britton was forced to buy the expensive MCHA coverage because of a pancreatitis diagnosis. He calls the idea that high-risk pools are good for consumers “a lot of baloney.”

“That is catastrophic cost,” Britton says. “You have to have a good living just to pay for insurance.”

And that’s the problem with high-risk pools, says Stefan Gildemeister, an economist with Minnesota’s health department.

“It’s not cheap coverage to the individual, and it’s not cheap coverage to the system,” Gildemeister says.

MCHA’s monthly premiums cost policy holders 25 percent more than conventional coverage, Gildemeister points out, and that left many people uninsured in Minnesota.

“There were people out there who had a chronic disease or had a pre-existing condition who couldn’t get a policy,” Gildemeister says.

And for the MCHA, even the higher premiums fell far short of covering the full cost of care for the roughly 25,000 people who were insured by the program. It needed more than $173 million in subsidies in its final year of normal operation.

The American Hospital Association, American Medical Association, and American Association of Retired Persons have all denounced the revised GOP proposal, The Hill’s Peter Sullivan reports. Vox’s Sarah Kliff points out that the parts of the ACA that states would be able to drop under the new amendment are among the most population provisions; 70% of those responding to a recent Washington Post/ABC News poll support requiring all states to protect those with pre-existing conditions, and 62% approve of requiring essential health benefits.

Allowing states to get waivers for essential health benefits, community rating, and age rating requirements of the ACA would be in addition to what the AHCA already would do to slash Medicaid and shrink subsidies for all but the youngest low-incomes purchasers of marketplace plans, resulting in an estimated 24 million people losing insurance. The original AHCA, as Kim Krisberg noted, “will cause unnecessary suffering and death.” With this amendment, a bill that was already bad for public health has become even worse.

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