Get Your Health Insurance Through Your Employer? Here's How the ACA Repeal Could Affect You
Provisions affecting healthcare for almost everyone may be affected, not only those who bought a marketplace plan
Much of the fuss over the planned repeal of the Affordable Care Act (ACA) has focused on the 20 million Americans who are at risk of losing their health insurance if the law is repealed. However, they are not the only ones who will be affected.
Those who get their insurance through their employer—an estimated 150 million people—might also lose certain consumer protections that they currently expect their job-based plan to provide.
Most people tend to associate the law with the online marketplace through which people who do not have insurance through their employer can buy a plan with a premium subsidy. Although most of those people say that they are happy with the coverage they have bought on the marketplace, many have had to face rising premiums and deductibles without a subsidy because they earn too much to qualify for one.
President Trump and many Republicans in Congress have called the law—which they disparagingly refer to as "Obamacare"—a "disaster" and have promised to repeal it. However, so far they have not agreed on how to replace it.
Some, including Trump, have said that they want to keep some of the benefits of the ACA—such as coverage for people who have a pre-existing condition—while eliminating the taxes that have helped pay for them. However, many analyses have suggested that doing so would disrupt the insurance market and lead to even more expensive premiums and deductibles.
Provisions that affect health care for almost every American will be affected by the outcome of this debate. Here are some of the ways that could happen:
Under the ACA, all new health plans must pay for recommended preventive services with no out-of-pocket payments for consumers, including health plans sponsored by employers. This requirement means that people can get a screening like a mammogram or a colonoscopy without having to meet an expensive deductible or co-payment first. Plans also have to pay for all forms of contraception approved by the Food and Drug Administration without cost-sharing, though there are limited exceptions in place for religious employers. Seventy-one million Americans got new benefits due to this requirement.
Before the ACA was passed, an employee who had a pre-existing condition sometimes had to wait up to one year after they were hired at a large company before the plan would cover that condition. Smaller companies could refuse coverage for such employees or charge them more than they charged employees without a pre-existing condition. Such discrimination is prohibited by the ACA.
"You don't have to suffer from what we call job-lock anymore," said Brendan Riley, a health policy analyst with the North Carolina Justice Center. "You don't have to stay in a job just to keep health insurance."
Before the ACA was passed, employers could make new employees wait indefinitely before becoming eligible to get coverage under the company plan. Now employees must not have to wait more than 90 days.
Annual and Lifetime Limits
Employer-based health plans are prohibited by the ACA from setting an annual or lifetime limit on how much the plan will pay for "essential health benefits" that the law outlines. Prior to the ACA, even the most generous plans often had a limit or cap on these benefits.
"A lot of insurers had a $1 million cap," said Michael Matthews, assistant professor of health care management at Winthrop University. "You'd be amazed in health care how fast you can go through $1 million. If you have a baby born premature in a hospital, you will hit that cap fast."
The U.S. Department of Health and Human Services estimates that 70 million people in large employer plans, 25 million in small employer plans, and 10 million with individual plans had lifetime limits prior to the passage of the ACA.
The ACA restricts how much people have to pay out-of-pocket every year. However, so-called "grandfathered" plans that existed before the law was passed are not included in this restriction.
The limit for one person's out-of-pocket costs in 2017 is $7,105, while the limit for families is $14,300.
"It's a safeguard to ensure that you aren't going broke from health care costs," Riley said.
Large employer plans do not have to include the same 10 "essential health benefits" as individual and small-group plans under the ACA. However, large companies do have to offer plans meeting a "minimum value" standard.
"This prevents employers from offering really skimpy plans that don't cover anything," Riley said. "There's a minimum value that plans have to meet so that people aren't on the hook for huge medical bills when they go to use their insurance coverage."
Coverage for Dependents until Age 26
All plans—including large employer-sponsored plans—have to cover dependents until they turn 26 under the ACA, even if those dependents are married, financially independent, and live in a different state. Before the law was passed, young adults made up one of the fastest-growing groups of the uninsured. The number of young adults with insurance has risen dramatically since the ACA was passed, especially among those who have a plan through an employer. This is another provision that Republicans have said they want to keep.
Standard Summary of Benefits
The ACA requires every plan to provide consumers with a "summary of benefits and coverage" in a standard format letting consumers understand their coverage and make comparisons. There are summaries available to view on HealthCare.gov, and, according to Riley, "because of the ACA, employer plans are supposed to provide that same thing."
Equal Mental Health Coverage
Prior to the ACA, small-group health insurance plans were not required to cover mental health and substance use disorder services. Now, such small employers—those with 50 employees or fewer—not only must include these services, they also have to offer coverage comparable to that for general medical and surgical services. According to the federal government, more than 23 million people in new small-group plans were able to access these benefits due to the ACA.
A previous federal law already required plans offered by large employers to offer just as much behavioral health coverage as medical coverage.
Limits to ER Costs
Under the ACA, if a consumer has to go to an out-of-network emergency room, he or she must be charged the same co-payments or co-insurance that they would at an in-network hospital. However, the facility can still "balance bill" the consumer for any costs that exceed those covered by the insurance plan. Non-profit hospitals must post online financial assistance policies outlining eligibility requirements for free or discounted care.