Most coverage of the planned repeal of the Affordable Care Act has focused on the 20 million people who might lose their health insurance if President Barack Obama’s signature health care law is dismantled by Republicans in Congress.
But people who get insurance through their employers – an estimated 150 million Americans – may also lose consumer protections they have come to expect from their job-based plans.
Most people associate the ACA with the online marketplace that offers health plans, with premium subsidies, to people who don’t get employer-sponsored insurance. Most people say they’re pleased with that coverage, but many individuals who earn too much to qualify for subsidies have complained bitterly about rising premiums and deductibles.
President-elect Donald Trump and congressional Republicans have called the ACA a “disaster” and pledged to repeal the law, which they refer to pejoratively as “Obamacare.” But their zeal for repeal hasn’t been matched by a consensus about what should replace it.
Trump and others have said they’d like to keep some of the ACA benefits while getting rid of taxes that have helped pay for them. But several analyses suggest this would disrupt the insurance market and result in even higher premiums and deductibles.
Depending on the outcome of the debate, some provisions that affect the health care for nearly every American – not just those who bought insurance through the marketplace – could be in jeopardy. Here are some examples:
The ACA requires all new health plans, including those sponsored by employers, to cover recommended preventive services with no out-of-pocket payments. This means people can get screenings, such as mammograms and colonoscopies, without having to first meet a costly deductible or co-payment. It also requires that plans cover all forms of Food and Drug Administration-approved contraception without cost-sharing. (There are limited exceptions for religious employers). This requirement brought new benefits to 71 million Americans.
Prior to the ACA, employees hired by large companies sometimes had to wait up to a year for the health plan to cover a pre-existing health condition. Smaller companies were allowed to refuse coverage or charge more for employees with pre-existing conditions. The ACA prohibits discrimination against employees with pre-existing conditions. Trump has said he’d like to keep this provision.
“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.”
Employers used to be able to make new employees wait indefinitely before becoming eligible for coverage under the company plan. Now the waiting time can be no more than 90 days.
Annual and lifetime limits
The ACA prohibits employer-based plans from setting annual or lifetime limits on what insurance will pay for “essential health benefits” outlined in the law. Before the ACA, even the most generous plans often had caps on 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.”
Estimates are that 70 million people in large employer plans, 25 million in small employer plans, and 10 million with individual plans had lifetime limits on benefits before the ACA, according to the U.S. Department of Health and Human Services.
The ACA sets limits on how much individuals will pay out-of-pocket each year. (”Grandfathered” plans that existed before the ACA are not subject to this provision.)
In 2017, the limit for individuals is $7,105, and 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.
The ACA doesn’t require large employer plans to include the same 10 “essential health benefits” that individual and small-group plans must include. But it does require large companies to offer plans that meet 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.”
Dependent coverage to age 26
The ACA requires all plans, including those sponsored by large employers, to cover dependents up to age 26, even if they’re married, financially independent and live in another state. Before the ACA, one of the fastest growing groups of uninsured was young adults. Since the ACA, there has been a dramatic increase in the number of insured young adults, particularly among those with job-based coverage. Republicans have said they’d like to keep this provision.
Standard summary of benefits
The ACA requires all plans to provide a “summary of benefits and coverage” in a standard form that allows consumers to understand their coverage and make apples-to-apples comparisons. Summaries can be found on HealthCare.gov, and “because of the ACA, employer plans are supposed to provide that same thing,” Riley said.
Mental health parity
Before the ACA, small-group health plans did not have to cover mental health and substance use disorder services. Under the law, these small employers (50 employees and under) not only have to include these services, they must offer coverage that is comparable to that for general medical and surgical care. More than 23 million people in new small-group plans gained access to these benefits with the ACA, according to the federal government. An earlier federal law already required large employers’ plans to offer behavioral health coverage at parity with medical coverage .
Limits on ER costs
If you land in an emergency room that is not part of your insurance plan’s network, the ACA requires all health plans to charge patients the same co-payments or co-insurance for out-of-network emergency care as for hospitals that are in-network. The hospital may still “balance bill” the patients for costs that exceed what the insurer reimburses. Non-profit hospitals are required to post online financial assistance policies that outline eligibility requirements for free or discounted care.
Other provisions of the ACA, unrelated to job-based health plans, that have become familiar to consumers could go away, depending on the extent of “repeal and replace” efforts.
▪ Black lung: Two amendments were meant to make it easier for longtime coal miners with black lung disease to get disability benefits. They are referred to as the “Byrd amendments,” for late Sen. Robert C. Byrd (R-W.Va.), who wrote them.
One allows widows of coal miners who received federal black lung benefits to continue receiving them after their husbands die. The other says a worker with at least 15 years in the mines and disabling breathing problems is presumed to have black lung. That shifted the burden of proving that the disability was directly caused by working in the mines away from the victim to the company.
▪ Menu calorie counts: Most restaurants and fast food chains with at least 20 stores are required to post calorie counts of their menu items.
▪ Employers are required to provide a place and time for women to express breast milk for up to a year after giving birth. The place must be private, other than a bathroom. In addition, most plans must offer breast-feeding support and equipment, such as pumps, without a co-pay.
Kaiser Health News contributed