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Republicans are a step closer to replacing the Affordable Care Act after the House approved its health care overhaul this week.
The American Health Care Act narrowly passed the House in a 217-213 vote on May 4 and now goes to the Senate, where it could face major revisions over several weeks.
There is a lot about the bill that is still unknown, such as the scope of its potential impact and cost.
Here’s what we know so far.
What does the bill mean for pre-existing conditions?
House Republicans have assured that pre-existing conditions will remain covered. But that’s a misleading line.
An amendment by U.S. Rep. Tom MacArthur, R-N.J., said nothing in the House plan "shall be construed as permitting insurers to limit access to health coverage for individuals with pre-existing conditions."
That’s in conflict with other language in the bill that could mean people with pre-existing conditions could end up paying more for coverage than they do now.
The MacArthur amendment allows insurers to set premiums based on the "health status" of an individual, which means that costs rise for consumers who are sicker. (Republicans later put in an extra $8 billion to subsidize people whose premiums skyrocket.)
The legislation allows states to set up a high-risk pool or participate in a new federal invisible risk-sharing program to help states reimburse insurers for covering high-risk consumers. But experts have noted some problems with high-risk pools that were used in many states in the past.
Does it make sexual assault a pre-existing condition?
The Republican bill loosens protections on all pre-existing conditions. But it doesn’t single out sexual assault, or any other specific medical event or diagnosis. That’s something the insurance companies or individual states would decide.
Prior to the Affordable Care Act, some victims of sexual assault said they had trouble getting health insurance because they sought medical services that the insurance companies viewed as evidence of a pre-existing condition, such as for sexually transmitted illness or mental health.
The Republican bill might make it harder for people who have pre-existing conditions to get affordable health care coverage, including victims of sexual assault. But we don’t know for sure given the bill’s current form.
How much will it cost?
It’s hard to say precisely because the Congressional Budget Office has not officially analyzed the most-recent version of the bill.
CBO’s previous estimate found that the original plan would reduce federal deficits by $337 billion between 2017 and 2026.
According to CBO, the biggest savings would come from reductions in spending on Medicaid and from eliminating the Affordable Care Act’s subsidies for people buying insurance outside an employer’s plan. Much of the revenue loss would come from eliminating several taxes that largely affect wealthy Americans.
But while spending would be dropping faster than revenues, this deficit reduction would come at a cost. CBO estimated that 24 million more Americans would lack health insurance in 2026 under the proposed law than under current laws.
What happens to federal money for Planned Parenthood?
The bill would effectively block Planned Parenthood from securing reimbursements from Medicaid -- not just for abortions, which is already the case, but for any services, from pap smears to birth control.
Planned Parenthood says the current arrangement walls off abortion services from those that have nothing to do with abortion. But abortion opponents have long argued that the government is tacitly supporting abortion even by reimbursing Planned Parenthood for non-abortion services, saying such money is fungible once it reaches Planned Parenthood’s coffers.
The change could have a significant impact on Planned Parenthood: About 43 percent of the group’s budget comes from the government, including grants and reimbursements, much of which comes from Medicaid. The group says the change, if enacted, could lead to closures of clinics and leave women without access to vital services, especially in medically underserved areas.
What happens to the individual mandate?
Under the bill, the Affordable Care Act’s tax penalty for not having minimum essential coverage is eliminated.
However, a late-enrollment penalty applies for people buying individual coverage who have not maintained continuous creditable coverage, such as a group health plan, Medicare or Medicaid.
What happens to people who have insurance through their employer?
The House legislation gets rid of the tax penalty for large employers that don’t provide health benefits.
Without the penalty, the nonpartisan Congressional Budget Office expected fewer employers would offer health insurance if the plan becomes law.
Health experts (such as Matthew Fiedler, a fellow with the Center for Health Policy in Brookings' Economic Studies Program) say employer plans could be affected in terms of caps and out-of-pocket expenses.
The Wall Street Journal explained how that could play out it: "If a state did away with a requirement to provide mental health and substance abuse services, employer plans using that benchmark could impose lifetime caps on the amount of mental health coverage they are willing to pay for."
What happens to Medicaid?
We only have CBO’s analysis of the first version of the bill, so these numbers could change.
According to that assessment, under the proposed law, Medicaid enrollment would drop by 14 million, or 17 percent, and federal funding would fall by $880 billion, or 25 percent, over the next 10 years.
The major changes would start in 2020, when the Republican bill would essentially start to phase out federal support for the Medicaid expansion passed under the Affordable Care Act, or Obamacare.
Under current law, the federal government incentivizes states to expand Medicaid eligibility by covering the vast majority of these newly eligible enrollees’ medical costs.
Lowering the federal share of Medicaid costs also lowers the incentive for states to expand eligibility, and the CBO expects no new states would expand under the Republican plan. It also notes that states that already have expanded eligibility could reverse course if federal funding shrinks because of the new bill.
How will it affect people with plans purchased through the state or federal exchanges?
If consumers buy on the exchange and their state gets a waiver, their plans could not cover certain benefits or they could be charged more.
Have a question about the proposal, or hear a questionable claim about it from leaders in Congress or pundits on TV? Email us at [email protected]
U.S. Rep. Fred Upton, Upton on Updates to the American Health Care Act, May 3, 2017
Kaiser Family Foundation, Compare Proposals to Replace The Affordable Care Act, accessed May 5, 2017
Ed Week, Health Care Bill's Changes to Medicaid Alarm School Advocacy Groups, May 4, 2017
PolitiFact, "Did Paul Ryan flip-flop on how to pass a big health care bill?" May 4, 2017
PolitiFact, "Headlines that say GOP bill makes sexual assault a pre-existing condition are misleading," May 5, 2017
PolitiFact Florida, "Does the GOP's new health care bill still cover pre-existing conditions, as Trump claims?" May 1, 2017
Washington Post The Fact Checker, "Kevin McCarthy’s claim that ‘nobody on Medicaid is going to be taken away’," May 5, 2017
Wall Street Journal, "GOP Health Bill Jeopardizes Out-of-Pocket Caps in Employer Plans," May 4, 2017
Interview, Matthew Fiedler, Fellow at the Center for Health Policy at Brookings Institute, May 5, 2017