What does Congress’s bill to repeal ACA and change Medicaid mean for people with disabilities?

A comparison of the current Affordable Care Act with the proposed House Republican bill, and brief analysis of impact on people with disabilities is included below.

The National Academy for State Health Policy has prepared a detailed comparison here: http://nashp.org/wp-content/uploads/2017/03/NASHP-ACARepealImpactsChart_MarchHouseBills_3.7.17.pdf

Additional updates will be made as further information becomes available.

 

 Under the ACA (Obamacare) Proposed House Republican Bill
Medicaid funding.

Currently, if a person meets the eligibility requirements (generally poverty, age, and/or disability), he or she is entitled to the services available under the state Medicaid program. The federal government pays ~60% of whatever it costs to provide services to people in a Medicaid program (like Family Care or IRIS). The state pays the remaining 40%. Medicaid funding expands to cover more people if needed, and contracts if fewer people need services.

Change

The bill would cap federal funding per enrollee, based on how much each state was spending in fiscal year 2016, and would set different spending limits for different populations (older adults, people with disabilities, kids, etc.).

Impact on People with Disabilities

Per Capita Caps Restricts and reduces the amount of funding provided to states for Medicaid, may not give states a sufficient amount to cover all Medicaid costs needed by an individual or a state Medicaid program as a whole, Passes decisions on cutting Medicaid costs to states, do not adjust or account for rising health care or prescription costs or changing needs of individuals or populations, do not account for higher cost individuals and populations with more complex needs, do not automatically increase per capita allocations for individuals whose needs change or become more intense, do not provide extra federal funding to help states handle unanticipated higher costs due to epidemics, natural disasters, medical advances, or demographic changes such as the growth of the frail elderly population.

To reduce Medicaid spending, states could: Limit or eliminate some services or supports; Establish wait lists for programs or services; Establish “tiered” benefits for certain populations; Restrict who is eligible for Medicaid * eliminate coverage for whole populations or subpopulations ; Add requirements, like cost-sharing, for participants; Eliminate entitlement to Medicaid; Use prior authorization or other methods to reduce or restrict access to services; Cut reimbursement rates for care providers *Or other mechanisms to reduce Medicaid costs

Addition

In addition to changing Medicaid to a Per Capita Cap system (see above), any state that exceeds their cap will receive reductions to their federal Medicaid funding in the following fiscal year.

Impact on People with Disabilities

Proposal would reduce federal Medicaid funding if caps are exceeded, incentivizing States to find ways to ensure all costs are covered within the federal allocation. This may force states to change eligibility, benefits, and provider payments.

Addition

Uses Federal Fiscal Year 2016 (Oct 1, 2016) as the budget base year to establish a Per Capita limit for spending the elderly and disabled and children.

Impact on People with Disabilities
FFY 2016 does not reflect Wisconsin’s current Medicaid budget. Wisconsin’s statewide expansion of Family Care and the proposal to end the children’s waiting lists are not reflected in the FFY 2016 base budget. This would mean that the Per Capita Cap would roll back to funding levels that do not account for hundreds of people on the adult long term care waiting lists, children on the CLTS waiting list, and unserved populations that were unaccounted for in Medicaid budgeting prior to 2016. Increases to FMAP or other fluctuations that increase federal match for other Medicaid programs that occurred after October 2016 would also not be reflected in the base budget used to calculate the proposal’s Per Capita Cap.

Requires that all state Medicaid Plans and ACA exchange plans must provide the same 10 essential health benefits Repeal
Repeals the requirement that Medicaid plans must provide the same 10 essential health benefits required of ACA exchange plans.Impact on People with Disabilities
As of December 2019, removes requirements that states must provide the 10 essential health benefits (including habilitative services, mental health and substance abuse services, etc.) in addition to the 8 mandatory core services that are required under Federal Medicaid law. States can choose to reduce the number and types of optional services they provide under their Medicaid State Plans. Wisconsin supports all the optional services allowable under Medicaid; all services provided under Family Care and IRIS are optional.
 The ACA included programs and state options to incentivize home and community based long term care services and supports to keep people in their homes. Repeal
Then enhanced financial incentives for states to increase home and community based servicesImpact on People with Disabilities
By 2020 when per capita caps go into effective states will have the ability to evaluate whether they maintain their HCBS (including, CLTS, IRIS, etc.).
 Dependent coverage until age 26 Keep
Requires coverage of Pre-existing conditions Keep
However, the requirement for all individuals to purchase insurance was intended to provide the funding needed to support higher cost individuals. If healthy younger people do not continue to purchase insurance, many analysts are unsure how higher cost individuals will be sufficiently funded.
Prohibits annual and lifetime coverage limits  Keep
Requires individuals to purchase health insurance Repeal
The bill eliminates the requirement for individuals to purchase insurance. Proposes a “continuous coverage incentive” which will impose a 30% penalty for any lapses in health coverage.Impact on People with Disabilities
Currently healthy people purchasing insurance offset the increased costs of providing care to people who have chronic conditions, are older, and have higher cost care. If fewer healthy people buy insurance that may drive up health care prices for older people, people with disabilities, and the chronic conditions.
Requires large employers to provide affordable insurance to employees Repeal
Impact on People with Disabilities
Workers with disabilities currently insured under an employer plan may lose coverage if their employer chooses to cut back or eliminate their employer sponsored insurance. People with disabilities could face increased premiums, higher deductibles, increased co-payments or other impacts. If individuals cannot find an affordable
 Requires the federal government to help some people pay deductible and co-payments Repeal
Federal tax credits to help people offset their health care costs expire in 2020.
Impact on People with Disabilities
May impact the number of healthy people who can afford to purchase insurance plans. If fewer healthy people buy insurance that may drive up health care prices for older people, people with disabilities, and the chronic conditions.
 Currently the ACA provides tax credits to middle income people on a sliding scale according to income to help offset premium and deductible costs. Change
Uses age instead of income to calculate the value of the tax credit an individual will receive and caps the credit at a fixed amount ($2000 for people under 30 and $4000 for people over 60).
Impact on People with Disabilities
Several analyses project that the tax credit amounts will be reduced than if the current law was maintained. As costs go up, the money from tax credits will cover a smaller proportion of the cost of care. People with higher cost health care needs will receive less of an offset to cover their expenses.