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ACA Repeal and Replace: How Will Chronic Pain Patients Fare?

April 4, 2017
House Republicans have passed a replacement bill to replace the Affordable Care Act. Many patients worry about costs and exceptions about pre-existing conditions. Now the Senate will decide.

The proposed bill that would repeal and replace the Affordable Care Act (Obamacare) has gotten mixed reviews from medical associations and patient groups.Original article has been updated to reflect new vote.

On May 4, House Republicans voted to approve their amended plan to replace the Affordable Care Act. The plan now moves to the Senate for debate.

The original house plan unveiled on March 6, called the American Health Care Act (AHCA), involved sweeping changes to both access and funding. These changes were too drastic for most citizens, who came out in large numbers to protest the bill. The bill failed to garner enough support.

The revised bill, which was amended to appeal to the more conservative wing of the party, eliminated the requirement to buy insurance through the marketplaces created by ACA, as well as the tax penalty for failing to buy health insurance.

By most estimates, the ACA provided coverage to an additional 20 million Americans. Many of the newly covered are worried that the new bill might change that. According to a recent Practical Pain Management (PPM) survey, 67% of physicians say their patients expressed concern that an ACA repeal might prevent them from seeing their doctors.

According to the Kaiser Family Foundation, the AHCA would provide less assistance to both older and lower-income Americans, especially those living in rural areas. The American Medical Association (AMA), the American Academy of Family Physicians (AAFP), and the American Academy of Pediatrics, as well as other groups, have also expressed concern that the new plan could leave many who now have insurance uninsured and without adequate care.

But others welcome changes to the ACA, which they blame, at least in part, for adverse changes to insurance coverage and physician reimbursement. Jeff Gudin, MD, director of pain management and palliative care at Englewood Hospital and Medical Center in New Jersey, said physician compensation has been unfairly calculated and points to the typical 30-minute appointments required for chronic pain patients being reimbursed at the same rate as routine patient visits lasting only 10 minutes.

House Proposed Changes

Tax Credits

Both plans use tax credits to help people pay for health insurance, but they do so differently. The ACA bases tax credits on the amount an individual can afford to pay (income level) as well as where he or she lives. Since insurance premiums vary by region, location can make a significant difference in cost.

By contrast, the House Republican plan would eliminate the income-based tax credits and subsidies with an age-based tax credits, ranging from $2,000/year for people in their 20s to $4,000/year for those older than 60, without regional adjustments. While this simplifies the credits, the flat amount won't go as far to cover costs in states where insurance premiums are higher.

Insurance companies would also be able to charge older Americans up to 5 times the rate they charge their youngest customers. And the plan would eliminate the ACA cost-sharing provision that reduces out-of-pocket costs. According to Kaiser Health News, actual subsidies under the ACA “help people with incomes between 100% and 250% of poverty [$12,060 to $30,150 for an individual] pay their deductibles and coinsurance or copays."1

At this early stage, it is uncertain how the new plan would affect physician reimbursements or payments to hospitals.

Potential Effects

The prevalence of pain increases with age. According to most estimates, 53% of Americans over 65 report persistent pain.1 Since the new plan subjects those 60 and above to higher premiums than their flat tax credit may cover, their costs are likely to rise. Patients who rely on adjuvant services, such as physical therapy (PT), may also face higher copays and deductibles.

Dalia Elmofty, MD, assistant professor of anesthesia and critical care at the University of Chicago, said her pain patients’ biggest worries are higher premiums and increased restrictions on care. “There are a lot of unanswered questions and concerns that are causing anxiety,” she said.

Tax Changes

Several taxes that helped pay for the ACA will be scrapped under the new law. Individuals earning over $200,000 (or $250,000 for married couples) will no longer be subject to a 0.9% surcharge on their income or to a 3.8% investment tax. The new plan also eliminates levies on medical devices, insurance plans, and pharmaceutical companies starting in 2018, and the so-called “Cadillac” tax that was to be charged for high-end employer-provided insurance plans will be suspended until 2025. According to the Committee for a Responsible Federal Budget, a non-partisan organization, a total of about $600 billion of tax revenue will be eliminated under the new plan.

Medicaid Changes

Under the ACA, Medicaid coverage became available to all those under 65 earning less than 138% of the poverty level; three-quarters of them report having pain in more than 1 location.2 Thirty-one states elected to participate in this open-ended coverage, which has provided health insurance to millions of low-income Americans.

The new bill would phase out Medicaid expansion starting in 2019 and impose a per-capita limit, drastically reducing federal funding and shifting the cost to the state and local levels. Those who enrolled in the Medicaid expansion coverage before 2020 will be able to keep their coverage as long as they do not allow it to lapse for more than 1 month after December. 31, 2019.

The new plan also converts Medicaid from an entitlement program into a grant program.

Under the new plan, insurers would still be required to provide the “10 essential benefits” designated by the ACA, including mental health care, which covers addiction treatment. But beginning in 2020, state Medicaid plans will no longer have to provide these benefits, which were expanded under the 2008 Mental Health Parity and Addiction Equity Act in order to ensure that care restrictions for mental health would not exceed those placed on other medical services.

Potential Effects

Once Medicaid drops the mental health care benefit, patients fighting opioid addiction are likely to lose coverage. “I am concerned that under the proposed healthcare reform proposals, there will be reduced funding for Medicaid and ACA exchange patients, higher copays and deductibles, all resulting in reduced access to therapies…including substance abuse treatment,” says Robert Rich Jr., MD, a family physician and pain management expert serving a rural population in North Carolina. Dr. Rich estimates that 30% of his patients currently receive Medicaid.

The Individual Mandate vs. “Continuous Coverage”

The ACA includes a mandate to purchase health insurance and imposes a tax penalty on those who do not. This rule helps insurance companies spread their risk and reduce costs by requiring that younger, healthier Americans buy insurance. Under the new plan, this mandate—as well as the requirement that companies with 50 or more full-time workers provide employee coverage—will be removed.

Instead of mandates, the AHCA allows insurers to charge 30% higher premiums for 1 year if customers let their coverage lapse for 63 days or more. This may happen if an individual leaves his job or gets laid off. It also applies to those with pre-existing conditions. While insurance companies could not deny coverage based on an individual’s health status, anyone allowing their coverage to lapse must pay the 30% surcharge, regardless of whether they have a pre-existing condition.

Potential Effects

The “continuous coverage” provision is especially worrisome for chronic pain patients who may lose employment when their condition is not controlled. The requirement to maintain coverage, as well as the proposed freezing of Medicaid enrollment, will disproportionately affect this population.

Whatever changes are adopted, Dr. Gudin said both chronic pain patients and physicians need to have “more skin in the game.”  He said, “Patients are going to have to accept that they need to begin paying for some of their routine care, and physicians will have to accept that all patients need to be treated regardless of their ability to pay."

Commenting on the proposed changes, Barby Ingle, president of the International Pain Foundation and a chronic pain patient herself, is not optimistic. The new plan “is not set up for [chronic pain patients], and our voice is being left out,” she said.

Last updated on: May 9, 2017

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