This week, I answer听questions听about how the Republican proposal to overhaul the health law could affect job-based insurance and what the penalties for not having continuous coverage mean.听Perhaps anticipating a spell of uninsurance, another reader wondered if people can rely on the emergency department for routine care.
Q: Will employer-based health care be affected by the new Republican plan?
The 听that recently passed the House would fundamentally change the individual insurance market, and it could significantly alter coverage for people who get coverage through their employers too.
The bill would allow states to opt out of some of the requirements of the Affordable Care Act, including no longer requiring plans sold on the individual market to cover 10 鈥�,鈥� such as hospitalization, drugs and maternity care.
Small businesses (generally companies with 50 or fewer employees) in those states would also be affected by the change.
Plans offered by large employers have never been required to cover the essential health benefits, so the bill wouldn鈥檛 change their obligations. Many of them, however, provide comprehensive coverage that includes many of these benefits.听听
But here鈥檚 where it gets tricky. The ACA placed caps on how much consumers can be required to pay out-of-pocket in deductibles, copays and coinsurance every year, and they听apply to most plans, including large employer plans. In 2017, the is $7,150 for an individual plan and $14,300 for family coverage.听Yet there鈥檚 a catch: The spending limits apply only to services covered by the essential health benefits. Insurers could charge people by the states.
Similarly, the law prohibits insurers from imposing lifetime or annual dollar limits on services 鈥� but only if those services are听related to the essential health benefits.
In addition, if any single state weakened its essential health benefits requirements, it could in every state, analysts say.听That鈥檚 because听these employers, who often operate in multiple states, which state鈥檚 definition of essential health benefits they want to use in determining what counts toward consumer spending caps and annual and lifetime coverage limits.
鈥淚f you eliminate [the federal essential health benefits] requirement you could see a lot of state variation, and there could be an incentive for companies that are looking to save money to pick a state鈥� with skimpier requirements, said Sarah Lueck, senior policy analyst at the Center on Budget and Policy Priorities.
Q: I keep hearing that nobody in the United States is ever refused medical care 鈥� that whether they can afford it or not a hospital can鈥檛 refuse them treatment. If this is the case, why couldn鈥檛 an uninsured person simply go to the front desk at the hospital and ask for treatment, which by law can鈥檛 be denied, such as, 鈥淚鈥檓 here for my annual physical, or for a screening colonoscopy鈥�?
If you are having chest pains or you just sliced your hand open while carving a chicken, you can go to nearly any hospital with an emergency department, and 鈥� under the federal (EMTALA) 鈥� the staff is obligated听to conduct a medical exam to see if you need emergency care. If so, they must try to stabilize your condition,听whether or not you have insurance.
The key word here is 鈥渆mergency.鈥� If you鈥檙e due for a colonoscopy to screen for cancer, unless you have symptoms such as severe pain or rectal bleeding, emergency department personnel wouldn鈥檛 likely order the exam, said Dr. Jesse Pines, a professor of emergency medicine and health policy at George Washington University, in Washington, D.C.
鈥淚t鈥檚 not the standard of care to do screening tests in the emergency department,鈥� Pines said, noting in that situation the appropriate next step would be to refer you to a local gastroenterologist who could perform the exam.
Even though the law requires hospitals to evaluate anyone who comes in the door, being uninsured doesn鈥檛 let people off the hook financially. You鈥檒l still likely get bills from the hospital and physicians for any care you receive, Pines said.
Q: The Republican proposal says people who don鈥檛 maintain 鈥渃ontinuous coverage鈥� would听have to pay extra for their insurance. What does that mean?听
Under the bill passed by the House, people who have a of more than 63 days in a year would be hit with a 30 percent premium surcharge for a year after buying a new plan on the individual market.
In contrast, under the ACA鈥檚 鈥渋ndividual mandate,鈥� people are required to have health insurance or pay a per adult. They鈥檙e allowed a every year before the penalty kicks in for the months they were without coverage.
The continuous coverage requirement is the Republicans鈥� preferred strategy to encourage people to get听health insurance. But some analysts have questioned how effective it would be. They point out that, whereas the ACA听penalizes people for not having insurance on an ongoing basis, the AHCA penalty kicks in only when people try to buy coverage after a break. It could actually discourage healthy people from getting back into the market听unless they鈥檙e sick.
In addition, the AHCA penalty, which is based on a plan鈥檚 premium, would likely have a greater impact on older people, whose premiums are relatively higher, and those with lower incomes, said Sara Collins, a vice president at the Commonwealth Fund, who authored an analysis of the impact of the penalties.
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