It's the young and healthy who are most likely to get locked out of coverage when they really, really need it.
When the American Health Care Act was on track to become the law of the land, it seemed like great news for the young and healthy, so long as they never got old or sick or poor. After all, in that first run at Trumpcare, the young and healthy were obvious winners: a 27-year-old in Mobile, Alabama, making $40,000 got an additional $600 tax credit, while a 60-year-old making the same amount lost $6,113. Insurers got the green light to charge older people five times what they charge young adults. And there was even talk of bringing back high risk pools—where sick people with high medical expenses would get separate insurance, which would cost them as much as $25,700 per year, in order to make insurance cheaper for healthy people. Wow! With benefits like that, why wouldn't everyone choose to be young and healthy?
But now Senate Republicans have made it harder even for young healthy people, especially women, to get healthcare. Their bill, the Better Care Reconciliation Act (BCRA), not only strips health insurance from millions (15 million in its very first year), but somehow manages to make the health care you get through your employer worse, though you may not know it until you really, really need it.
Young healthy people are more likely to be locked out of healthcare.
The great mystery of designing a health care plan is how to get people who think they will never get sick to buy insurance before their lives depend on it. Obamacare answered that with the individual mandate, which requires everyone to buy healthcare or face a penalty.
Getting rid of the mandate has been tricky for Republicans. On one hand, they need to get rid of it, because it is the core of Obamacare—by requiring healthy people to buy insurance, the costs of sick people are balanced. On the other hand, Republicans kinda like the idea of forcing people to buy stuff from the private market; in fact, conservative economist Milton Friedman called for "a requirement that every US family unit have a major medical insurance policy" in 1991 and an individual mandate was introduced by Republican Senator John Chafee's Health Equity and Access Reform Today Act of 1993.
The BCRA says it gets rid of the individual mandate, but it's a trap. "Young healthy people can now opt to go uninsured without a penalty," says Christine Eibner, a senior economist at RAND Corporation. "There's a catch though—if they decide to go without insurance, they could be faced with a six-month waiting period if they opt to enroll in individual market coverage."
That's the continuous coverage provision. In this installment of Trumpcare, if you go without insurance for more than 63 days, then you will be locked out of health care for six months, even if there is an open enrollment period. See! Trumpcare isn't all about taking health insurance from people who can't pay for it—this way, they screw over people who can pay for it, too!
Young people would be hit hard by this penalty. As many as one third of young people between 19 and 34 experience a coverage gap over the course of a year, according to the Young Invincibles, a health advocacy group. Because young people are more likely to move or change jobs, they are 70 percent more likely to have a coverage gap than older Americans.
Getting locked out of insurance for six months could be devastating, since emergencies don't wait for insurance companies to start caring about you—20 percent of young adults need to go to the ER every year, and women may not be able to stay on birth control, especially if Planned Parenthood is defunded, as the revised health plan does yet again.
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Young healthy women would be hurt the most
Getting rid of essential health benefits—either if states are allowed to waive them, as in the first version of the BCRA, or if Ted Cruz gets his wish and insurance companies can sell plans without them, as in the most recent draft—will hurt young, otherwise healthy women the most: As we've written before, the two biggest threats to a healthy woman's life aren't diseases, but violent men and pregnancy.
Obamacare required all insurance plans, including large employers, to provide domestic violence counseling and screening at no charge as a preventive health service, an essential health benefit. Before Obamacare, seven states could straight up deny health insurance to women because of domestic and sexual abuse.
It gets worse, too, for women who are pregnant. Before the ACA, only 12 states required insurers on the individual market to cover maternity care, and so 62 percent of people who purchased their own insurance did not have maternity coverage.
But since Republicans are great at inventing new ways to take health care away from people, now not even large employer-based healthcare is safe from these changes. One way that the Affordable Care Act made coverage affordable was by banning annual and lifetime limits for essential health benefits. "The ACA prohibited insurers from imposing annual or lifetime limits—for example, by telling enrollees that the plan will cover up to, say, $100,000 in spending and after that you're on your own," says Eibner. "But these limits only apply to the essential health benefits." That means getting rid of essential health benefits entirely or any one of them opens up the possibility that insurers could impose annual or lifetime limits once again.
"If a state were to waive one or more of the essential health benefits, insurers that offered this coverage could impose annual or lifetime limits on the excluded service," Eibner says. "If maternity care were eliminated from the benefit, an insurer that opted to cover maternity could set a cap. They could agree to cover up to $10,000 in maternity costs in a given year, but nothing over that." The average cost of maternity care and delivery, however, according to the Congressional Budget Office, is $17,000.
How many employers would actually be heartless enough to reintroduce annual limits if given the chance? Twenty percent, according to one recent survey. Fifteen percent said they'd impose lifetime limits and eleven percent said no to offering no-cost contraception if they aren't required to.
But cheer up, it's not all bad news. There are plans that will be required to keep essential health benefits: The ones for members of Congress.
Jason Silverstein is a lecturer and writer-in-residence in the department of global health and social medicine at Harvard Medical School and an Instructor at the Harvard TH Chan School of Public Health.
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