Vice President for Health Policy
With House supporters planning a new push for the Republican Study Committee (RSC) health plan (H.R. 3121), aided by RSC chairman Steve Scalise (R-LA)’s election as House majority whip, it’s worth looking at the plan’s likely impact. Unfortunately, it would substantially expand the ranks of the uninsured and end various important consumer protections.
Impact on the Number of Uninsured
The RSC plan would repeal health reform, including its Medicaid expansion, under which the federal government will pick up nearly the full cost of covering individuals up to 138 percent of the poverty line. The 13 million people whom the Congressional Budget Office (CBO) now estimates will gain Medicaid coverage in states that adopt the expansion would lose out.
It also would eliminate the new marketplaces through which millions of people are buying private coverage, as well as the premium tax credits and cost-sharing reductions that make marketplace coverage much more affordable for low- and moderate-income people. The loss of these subsidies would cause millions of new marketplace enrollees to lose their health coverage.
The RSC plan would also end the tax exclusion for employer-based coverage, replacing it with a standard income and payroll tax deduction of $7,500 for individuals (and $20,000 for families) who buy coverage on their own or through their employer. As CBO, the Joint Committee on Taxation, and others have previously estimated, this type of proposal would likely cause many people to lose their job-based coverage by encouraging employers to drop it on the assumption that their workers could use the deduction to purchase health insurance in the individual market. (Unlike current law, the plan would not require larger employers to either offer affordable, comprehensive coverage or pay a penalty.) But many workers in poorer health who lost employer-based insurance likely would be unable to find coverage in the individual market.
Moreover, the tax deduction would do very little to help most uninsured people gain coverage. Most uninsured people either don’t earn enough to owe income tax or are in the 10 or 15 percent tax bracket, so they would receive an income tax benefit of no more than 15 cents for every $1 they can deduct, along with a payroll tax benefit of 7.65 cents per dollar earned.
People who lose their jobs and have no earned income would receive no benefit, while a single poor adult earning $10,000 would receive no income tax benefit and a payroll tax benefit of about $574 a year, far below the cost of insurance. And, assuming the plan’s deduction was in place in tax year 2014, a single 64-year-old with income equal to twice the poverty line — $23,340 — would likely receive a total tax benefit of no more than about $1,530. That’s only about one-quarter of the tax credit that health reform provides, because health reform’s tax credit is refundable, more generous at lower incomes, and adjusted for age (as older people face higher premiums). Moreover, unlike under health reform, the RSC plan gives people with modest income no help with their deductibles and other cost-sharing charges.
The deduction would primarily benefit people in the top income tax brackets, who least need help in affording insurance and are the most likely already to have coverage. (Also, it’s unclear whether the payroll tax deduction would effectively result in lower Social Security benefits for individuals taking it, as well as lower contributions to the Social Security and Medicare trust funds that would hasten their insolvency.)
Impact on Consumer Protections
Health reform prohibits insurers in the individual market from refusing to cover people with pre-existing medical conditions. In contrast, the RSC plan would allow insurers to deny coverage in such cases, except for people who have had continuous coverage (through an employer or in the individual market) for at least 18 months. That’s only a modest improvement over the deeply flawed situation before health reform.
Thus, someone without job-based coverage who was denied coverage in the individual market because of cancer or diabetes would likely remain uninsured.
Moreover, people with pre-existing conditions who have had continuous coverage could qualify for individual-market coverage only through a high-risk pool. Such coverage likely wouldn’t be affordable. The high-risk pools could charge premiums twice as high as the standard premium, and standard premiums could vary based on age, with no upper limit.
More broadly, relying on high-risk pools to provide coverage would be “extremely expensive and likely unsustainable,” as the Commonwealth Fund has explained. That’s because they pool sick individuals not with healthy individuals — as regular insurance pools do to keep premiums stable and affordable — but with even sicker individuals who cost even more to insure.
Indeed, experience with state high-risk pools shows that unless government financial support for them rises significantly over time, the pools eventually have to sharply restrict enrollment, set premiums further above what many families can afford, and/or scale back coverage by reducing benefits or increasing deductibles and other cost-sharing, in order to keep costs from spiraling out of control. Yet the RSC plan provides no actual federal high-risk-pool funding. (It authorizes Congress to appropriate money for this purpose, but Congress may never do so, given the caps on funding for appropriated programs and the automatic “sequestration” cuts.)
Finally, the RSC plan would eliminate all of health reform’s consumer protections and market reforms. It would allow insurers to once again:
In another reversal, the RSC plan would allow insurers to leave big coverage gaps in the individual and small-group markets by omitting critical benefits such as prescription drug coverage or maternity care, as they could do before health reform. And by allowing out-of-state insurers to sell insurance within a state without complying with the state’s consumer protections, the plan also would undermine the insurance market reforms and protections that a number of states had put in place before health reform.
The bottom line? The RSC’s proposal would be a very large step backward that would drive millions of Americans, especially people of limited means, into the ranks of the uninsured and the underinsured.