Brief Summary of ACA Repeal Bills

Quick Jump

I. Introduction
II. Individual Mandate
III. Tax Credits/Insurance Subsidies
IV. Essential Health Benefits (“EHBs”)
V. Employer Mandate
VI. Age Ratings
VII. Changes to Benchmark Plans
VIII. Pre-Existing Conditions
IX. Medicaid Expansion
X. Medicaid Funding
XI. Young adults <26
XII. Planned Parenthood Funding and Abortions
XIII. Miscellaneous Taxes


I. Introduction

Congress is considering multiple bills that would substantially modify the Affordable Care Act (“ACA”).  This article provides a brief overview of each.

 

The Affordable Care Act (“ACA”) The American Health Care Act (“AHCA”) The Better Care Reconciliation Act (“BCRA”) The Obamacare Repeal Reconciliation Act (“ORRA”) Republican “Skinny Bill”
First introduced September 17, 2009.
Signed into law on March 23, 2010.
First introduced in the House of Representatives on March 6, 2017.
Passed by the House on May 4, 2017.
On June 22, the “discussion draft” of the Senate’s BCRA was released to the public.
There are several versions of the bill.  The key versions are the July 20th version and the version that include the Cruz and Portman Amendments.
The Senate voted “no” on the version that included the Cruz and Portman Amendments on July 25, 2017.
The Senate has also debated the ORRA, which would repeal nearly all the provisions of the ACA without replacing them.
Released on July 19, 2017.
The Senate voted against this bill on July 26, 2017.
Announced (but not released) on July 25, 2017 by Republican leadership.
Released to the public and introduced in the Senate simultaneously late into the evening on July 27, 2017, just two hours before the vote.
In the early hours of July 28, 2017, the Senate voted against this bill.

II. Individual Mandate

 

The Affordable Care Act (“ACA”) The American Health Care Act (“AHCA”) The Better Care Reconciliation Act (“BCRA”) The Obamacare Repeal Reconciliation Act (“ORRA”) Republican “Skinny Bill”
Everyone must be insured or pay a penalty. In 2016, the penalty was 2.5% of total income or $695 per person, whichever was higher. The individual mandate would not apply starting in 2016. However, there is a one-time 30% surcharge for individuals with >63 days gap in coverage. If applying during open enrollment, an individual must have no gaps in coverage longer than 63 days over the last year.

If applying under special enrollment, an individual must have either the above OR at least 1 day of coverage during the 60-day period immediately preceding the submission of an application.

If the individual has had a gap under either of the preceding circumstances, then they cannot have coverage for 6 months.  Policy applies beginning in 2019.
The individual mandate would not apply starting in 2016. The individual mandate would not apply starting in 2016.

 


III. Tax Credits/Insurance Subsidies

 

The Affordable Care Act (“ACA”) The American Health Care Act (“AHCA”) The Better Care Reconciliation Act (“BCRA”) The Obamacare Repeal Reconciliation Act (“ORRA”) Republican “Skinny Bill”
Income-based subsidies for individuals between 100% and 400% FPL; geographic location and premium increases taken into account. Amounts do not vary by age. Tax credits based primarily on age (ranging from $2,000 for individuals <30 years to $4,000 for individuals 60 years & up). Credit reduced by 10% of excess income above $75,000 per person or $150,000 per dual filers. Maintains ACA tax credits based on income and premium increases but lowers eligibility level for subsidies from 400% FPL to 350% FPL.
Does not allow premium tax credits for consumers with any offer of employer coverage.

 

Prohibits tax credits for small business employees who get help from their employers to purchase coverage on the individual market.


All consumers could use tax credits to purchase catastrophic plans starting in 2019.

There would be no premium tax credits or small business tax credits. This would leave the ACA’s tax credits in place.

IV. Essential Health Benefits (“EHBs”)

 

The Affordable Care Act (“ACA”) The American Health Care Act (“AHCA”) The Better Care Reconciliation Act (“BCRA”) The Obamacare Repeal Reconciliation Act (“ORRA”) Republican “Skinny Bill”
All insurance plans must cover 10 EHBs, including plans in the Medicaid expansion. States can seek a waiver of this requirement.  Removes EHB requirement from Medicaid expansion plans as of 2020. States may seek a waiver of this requirement for plans on the individual market.

 

The Cruz Amendment (which failed a procedural vote on July 25th) would permit states to waive the EHB requirement for insurers, so long as they also offer other plans that include EHBs.

There would be no premium tax credits. This would leave the ACA’s EHBs in place.

V. Employer Mandate

 

The Affordable Care Act (“ACA”) The American Health Care Act (“AHCA”) The Better Care Reconciliation Act (“BCRA”) The Obamacare Repeal Reconciliation Act (“ORRA”) Republican “Skinny Bill”
Employers with >50 employees must offer health insurance. Starting in 2016, there would be no employer mandate. Starting in 2016, there would be no employer mandate. Starting in 2016, there would be no employer mandate. From 2016 through 2026, there would be no employer mandate.

VI. Age Ratings

 

The Affordable Care Act (“ACA”) The American Health Care Act (“AHCA”) The Better Care Reconciliation Act (“BCRA”) The Obamacare Repeal Reconciliation Act (“ORRA”) Republican “Skinny Bill”
Prohibits insurers from charging older individuals more than 3 times what they charge younger individuals. Prohibits insurers from charging older individuals more than 5 times what they charge younger individuals OR states may obtain a waiver to determine any other ratio. Prohibits insurers from charging older individuals more than 5 times what they charge younger individuals OR states may obtain a waiver to determine any other ratio. There would be no federal restriction on the age ratio, though prior to the ACA, the average ratio of age variations was about 5:1. The ACA’s policy would remain in effect.

 


VII. Changes to Benchmark Plans

 

The Affordable Care Act (“ACA”) The American Health Care Act (“AHCA”) The Better Care Reconciliation Act (“BCRA”) The Obamacare Repeal Reconciliation Act (“ORRA”) Republican “Skinny Bill”
Insurers are required to label offerings by metal tier: Bronze, Silver, Gold, & Platinum. Tiers indicate to consumers how much is covered by insurance versus what is out of pocket (in addition to premiums).  Lowest plan (bronze) must have an AV of 60% (meaning consumer responsible for 40% of costs). Repeals metal tier system with no alternate plan for consumers to understand average out of pocket costs when comparing plans. Plans can be sold that cover less than 60% of all costs. Bronze plans must cover at least 58% AV.
The Cruz Amendment (which failed a procedural vote on July 25th) would permit states to waive the EHB requirement for insurers, so long as they also offer at least one gold plan (80% AV), one silver plan (70% AV), and one bronze plan (58% AV).
There would be no benchmark plans. The ACA’s policy would remain in effect.

 


 

VIII. Pre-Existing Conditions

 

The Affordable Care Act (“ACA”) The American Health Care Act (“AHCA”) The Better Care Reconciliation Act (“BCRA”) The Obamacare Repeal Reconciliation Act (“ORRA”) Republican “Skinny Bill”
Patients cannot be denied insurance coverage on this basis; community ratings prohibit charging more to a person based on pre-existing condition. People with pre-existing conditions must be covered but states can seek waivers that allow insurers to charge more based on health status. Maintains the ACA’s rules on pre-existing conditions, but states could waive the Essential Health Benefits requirement which could eliminate coverage for certain services that people with pre-existing conditions rely upon
The Cruz Amendment (which failed a procedural vote on July 25th) would permit states to allow insurance companies to consider pre-existing conditions when charging customers, as long as they also offer plans that do not consider pre-existing conditions.
Although Republican leadership claims that this bill would be a complete repeal and replace, the ORRA would leave in place the requirement that insurers may not discriminate against those with pre-existing conditions. The ACA’s policy would remain in effect.

IX. Medicaid Expansion

 

The Affordable Care Act (“ACA”) The American Health Care Act (“AHCA”) The Better Care Reconciliation Act (“BCRA”) The Obamacare Repeal Reconciliation Act (“ORRA”) Republican “Skinny Bill”
Expanded coverage to nondisabled adults with incomes <133% FPL. Ends the Medicaid expansion as of 2020. Does not directly end the Medicaid expansion, but gradually reduces federal funding from 2021 to 2023. Some states that expanded Medicaid would automatically end the expansion when federal dollars get reduced. As a result of these cuts to the Expansion, the CBO estimates 14 million fewer insured under the AHCA by 2026.  For the BCRA, the CBO estimates that 21 million fewer would be uninsured compared to the ACA. The ACA’s Medicaid Expansion would remain in effect.

X. Medicaid Funding

 

The Affordable Care Act (“ACA”) The American Health Care Act (“AHCA”) The Better Care Reconciliation Act (“BCRA”) The Obamacare Repeal Reconciliation Act (“ORRA”) Republican “Skinny Bill”
Continued historical funding method of federal government matching state spending dollar for dollar without caps. Allows states to choose block grants or per-capita caps as method of receiving federal matching funding; federal funds would no longer be tied to actual state spending needs;
federal increases based on the medical care component of the consumer price index.
Allows states to choose block grants or per-capita caps; federal funds would no longer be tied to actual state spending needs; federal increases based on medical care component of the consumer price index starting in 2021 and then switching to standard inflation starting in 2025.


It would also allow states to apply block grant funding for the Medicaid expansion population.  States could also exceed the block grant caps in the case of a public health emergency.

Federal funding for the Medicaid Expansion would phase out over two years.  States would likely need to reduce coverage for Expansion populations without the increased federal funding.  If the federal matching rate declines below what the ACA promises, the Expansion immediately ends in eight states. Medicaid funding would remain the same as under the ACA.

XI. Young adults <26

 

The Affordable Care Act (“ACA”) The American Health Care Act (“AHCA”) The Better Care Reconciliation Act (“BCRA”) The Obamacare Repeal Reconciliation Act (“ORRA”) Republican “Skinny Bill”
Young adults can stay on their parents’ plan. Young adults can stay on their parents’ plan. Young adults can stay on their parents’ plan. Young adults can stay on their parents’ plan. Young adults can stay on their parents’ plan.

XII. Planned Parenthood Funding and Abortions

 

The Affordable Care Act (“ACA”) The American Health Care Act (“AHCA”) The Better Care Reconciliation Act (“BCRA”) The Obamacare Repeal Reconciliation Act (“ORRA”) Republican “Skinny Bill”
Funding for Planned Parenthood is unrelated to the ACA.  (See details about how the Hyde Amendment works, which does not allow funding for abortions with state funds.  The Hyde Amendment is unrelated to the ACA.) Defunds Planned Parenthood (not just abortions) for 1 year.
Tax credits cannot be spent at all on any health care plan that covers abortion.
Medicaid cannot be used at Planned Parenthood
Defunds Planned Parenthood (not just abortions) for 1 year.
Alters the definition of a “qualified health plan” so as to prohibit consumers from receiving tax credits for any plan purchased on the individual marketplace that covered abortion care (unless the mother’s life is at stake or the pregnancy is a result of rape or incest).
Defunds Planned Parenthood (not just abortions) for 1 year. Defunds Planned Parenthood (not just abortions) for 1 year.

XIII. Miscellaneous Taxes

 

The Affordable Care Act (“ACA”) The American Health Care Act (“AHCA”) The Better Care Reconciliation Act (“BCRA”) The Obamacare Repeal Reconciliation Act (“ORRA”) Republican “Skinny Bill”
Implements many taxes, generating revenue for the federal government Eliminates and modifies many ACA taxes. Eliminates and modifies many ACA taxes. Eliminates all ACA taxes. Eliminates the medical device tax for three years.