Republicans in Congress have finalized an amended version of the American Health Care Act (AHCA), which is the Trump Administration’s proposed replacement for the Affordable Care Act (ACA). Ever since the AHCA was pulled from the floor on March 24, 2017 prior to voting, Congressional Republicans have been working to revise it. The new amendment, which was authored by Rep. Tom MacArthur (R-NJ) with help from the Freedom Caucus Chairman Rep. Mark Meadows (R-NC), was added to the bill in an effort to garner enough votes from conservative members of Congress for the health care bill to pass. This new amendment takes aim at popular provisions of the Affordable Care Act (ACA), including the preexisting condition discrimination ban and required insurance coverage of essential health benefits. These ACA provisions have been critical for expanding insurance coverage and health care access for people living with HIV (PLWH).
While the new amendment specifically states that “nothing in this act shall be construed as permitting health insurance issuers to limit access to health coverage for individuals with preexisting conditions,” health policy experts are concerned that this is actually what will happen in practice. The amendment allows states to waive out of ACA regulations that require insurance issuers to set premiums based off of the entire community of people buying coverage, regardless of any individual person’s preexisting health conditions. This means that in states that file for a waiver under the amended AHCA, insurance issuers could be allowed to charge people with preexisting health conditions, including HIV, higher premiums. States that apply for this waiver are required to participate in the Patient and State Stability Fund, which is a pool of money that could be used to set up a high-risk pool to offset costs for people with preexisting conditions, but experts believe that states are not specifically required to use the funds for this purpose. Passage of the amended AHCA would likely lead to decreases in coverage for PLWH in states that apply for a waiver.
The amendment would also allow states to waive out of mandating required coverage of essential health benefits, which includes core elements of health care such as annual physicals, prescription medication, routine cancer screenings, routine HIV/STI screenings, treatment for substance use, and mental health care. Required coverage of behavioral health care is critical for expanding access to care and reducing disparities, especially for PLWH who experience disproportionate behavioral health burden. Required coverage of HIV/STI screening and chronic disease treatment is critically important for preventing the transmission of HIV and improving the health and well-being of PLWH.
States can opt out of mandating insurance issuers to fully cover essential health benefits simply by showing that doing so would reduce the average premium costs for health insurance in the state. This will almost certainly be the case just due to the fact that fewer services will be covered. The amendment also includes default approval for waivers which means that applications for waivers are automatically approved, with the burden falling on the federal government to reject applications within 60 days if the state is not fulfilling its obligations.
This new amendment poses a threat to PLWH, who have benefitted greatly from the ACA provisions banning preexisting condition discrimination and requiring coverage of essential health benefits. Furthermore, the amended version of the AHCA still retains provisions of the original bill that are harmful to PLWH, such as ending Medicaid expansion in 2020, cutting Medicaid funding by switching to a per-capital cap funding system, and reducing subsidies for many low-income and older Americans.
The MacArthur Amendment takes a bad bill and makes it worse. If enacted, it would make it much more difficult for people with preexisting health conditions such as HIV to obtain health insurance that is affordable. This amendment seems designed to make it harder to obtain coverage for health care, not easier.
Tim Wang, MPH, is LGBT Health Policy Analyst for The Fenway Institute at Fenway Health. Sean Cahill, PhD, is Director of Health Policy Research for The Fenway Institute at Fenway Health. They are co-authors of the recently published policy brief, Amended American Health Care Act Poses New Threat To People Living with HIV, LGBT People.