Latest draft of AHCA still doesn’t measure up

Andrew W. Gurman, MD , Former President

Leaders of the House of Representatives on Monday unveiled several changes to the American Health Care Act (AHCA), their plan to repeal and replace the Affordable Care Act (ACA). Yet this latest version of their proposal still falls short where it matters most—maintaining the health care coverage gains that have been achieved in recent years.

As physicians, we know that uninsured patients live sicker and die younger than patients who have health care coverage. Nothing frustrates us more than having the knowledge and skill to help patients and yet lacking the meaningful ability to do so because patients are uninsured and cannot access care.

The tax-credit structure that forms the heart of the AHCA remains intact and simply does not measure up when it comes to helping Americans purchase health care coverage. As part of its comprehensive vision for health reform, the AMA has long called for tax credits that are refundable, advanceable, inversely related to individual income, and big enough to help people buy coverage. This means that Americans get financial help when they need it so they are covered when they need it. The AHCA will not achieve that goal.

Consider this: Under current law, a 40-year-old patient in Arostook County, Maine, who makes $20,000 a year pays $960 a year for health care coverage after a tax credit, according to analysis provided by the nonpartisan Kaiser Family Foundation. If the AHCA became law, that same patient would pay $4,390 in health insurance premiums after receiving the new, less generous tax credit—a 358 percent spike.

Multiply that impact across the millions of Americans whose health care coverage is at stake. More than 20 million Americans have gained coverage in recent years, yet under the AHCA, 24 million more patients would be uninsured by 2026, the Congressional Budget Office has said. There is little we see in this latest version of the AHCA that would dramatically affect that estimate.

For example, the AHCA still repeals the expanded version of Medicaid that allows people who earn up to 133 percent of the federal poverty line to qualify for coverage. And the AHCA would also change the basic structure of the traditional Medicaid program, making it less responsive to shifts in demands for medical services and threatening the vulnerable populations it serves.

In a letter sent today to House Speaker Paul Ryan and House Minority Leader Nancy Pelosi, AMA CEO and Executive Vice President James L. Madara, MD, described the potential effects of these elements of the AHCA.

“Medicaid expansion has provided access to critical services, including mental health and substance abuse treatment, for millions,” Dr. Madara wrote. “Not only will the AHCA force many states to roll back coverage to these millions of previously ineligible individuals, but the significant reduction in federal support for the program will inevitably have serious implications for all Medicaid beneficiaries, including the elderly, disabled, children and pregnant women.”

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Health reform: Patients deserve a healthier individual market

    In the ongoing debate about how to improve our health care system so that it better serves the needs of our patients, a lot of numbers get thrown around. But there is one relatively simple figure I heard recently that took me aback: $100. That was the amount by which Jose Sanchez’s annual income exceeded the income threshold under the traditional Medicaid program in New York state prior to passage of ACA.

    Because his income was too high, by less than 30 cents a day, Sanchez went uncovered so that he could keep the job he needed to support his family. But Sanchez lives with type 1 diabetes, and he tried to ration his insulin to make each prescription last longer. This led to entirely preventable trips to the hospital during which his children stayed with relatives.

    I was honored to share the stage with Sanchez and other patients at a National Press Club event last week in which the American Diabetes Association, American Heart Association, American Cancer Society Cancer Action Network joined the AMA in asking Congressional leaders and the Trump administration to go back to the drawing board on health reform.

    In the days since then, this modified version of the AHCA has emerged. Yet the proposal’s flawed reform blueprint remains the same. It is time to start fresh, to take the actions needed to stabilize and strengthen the individual insurance market, and to make other improvements to the ACA. In that venture, the AMA is eager and ready to engage.