Republican lawmakers tout lower premiums through association health plans, while Democrats warn of rising costs and coverage losses tied to ACA changes.
Congressional Republicans say they are taking steps on health care — but Democrats counter that previous efforts are already costing Virginians coverage and putting hospitals under strain.
Republicans have pointed to measures like the Rural Health Transformation Fund and an association health plan expansion bill that has cleared the House and is headed to the Senate. However, GOP reluctance to renew expired Affordable Care Act tax credits has led 33,000 Virginians so far to drop their health insurance.
At the same time, a GOP-backed reconciliation bill passed last summer includes forthcoming changes to Medicaid and hospital funding mechanisms — changes the rural health fund was designed, in part, to help offset.
As thousands more Virginians risk losing insurance and other health benefits, and hospitals brace to absorb more uncompensated care, Democrats argue their Republican colleagues are making the wrong moves and not doing enough to protect public health.
Three Virginia clinics have closed, and some hospitals have scaled back services — all citing the reconciliation bill as a contributing factor. Meanwhile, several Virginia hospitals have appeared on at-risk lists over the past year, underscoring the vulnerabilities of certain facilities.
With polling showing health care affordability and access as key issues heading into the congressional midterms, both parties are highlighting their competing proposals.
‘Lower Health Care Premiums For All Americans Act’
As states like Virginia begin implementing their share of the Rural Health Transformation Fund’s $50 billion nationwide allocation, Congress is advancing the “Lower Health Care Premiums For All Americans Act.”
Spearheaded by U.S. Rep. Mariannette Miller-Meeks, R-Iowa, the legislation would expand association health plans by allowing small businesses and self-employed people to band together to purchase insurance.
On a call with reporters in her state last December, Miller-Meeks said the proposal focuses on changes that “actually lower costs and put patients and doctors back in charge, and back in the driver’s seat.”
That line has also been echoed by Virginia Rep. Rob Wittman, R-Westmoreland, in a recent call with The Mercury to discuss the bill and broader health care policy.
“Anything that you buy in bulk or in mass or in quantity, you get a reduction in price,” he added. “And that’s what the idea is here.”
Sabrina Corlette, a researcher with Georgetown University’s Center on Health Insurance Reforms, said association health plans have existed for decades. What changed when the Affordable Care Act came about 16 years ago, she noted, is that AHPs were no longer allowed to use a person’s health risk to determine the premiums they pay.
“We don’t do enough to encourage patients to pursue preventive care and healthier lifestyles,” Wittman said. “It’s about a system based on reimbursement for treatment, not trying to put resources out there for healthy behaviors.”
The debate ties back to a longstanding Republican critique of the ACA’s treatment of preexisting conditions. Before the law, private insurers and association health plans could deny coverage based on factors such as chronic illness or a history of cancer. The ACA prohibited those practices and required broader risk pooling, meaning older or less healthy individuals are grouped with younger, healthier enrollees.
Corlette said that factor effectively results in healthier people paying the similar premiums to those who are older or managing chronic conditions.
“They are subsidizing sicker folks, that’s just a fact,” she said.
Corlette said Republicans aim to lower premiums for healthier individuals by allowing risk-based pricing, while Democrats generally approach the issue from a broader social protection standpoint.
“We all get older and sicker,” she said. “(The Democrats’ approach) is recognizing that you might be subsidizing a sicker person today, but someone else will be subsidizing you down the road.”
Healthinsurance.org analyst Louise Norris described the bill as “a solid wishlist” for Republicans seeking to expand private consumer choice in health care and chip away at the ACA.
She added that both parties are correct in highlighting the risks and rewards of Miller-Meeks’ proposal, as some consumers could benefit from lower premiums while others may face higher costs.
Another component of the bill includes a provision to codify a type of insurance premium reimbursement that employers sometimes agree to with their employees. Branded as “Custom Health Option and Individual Care Expense,” or CHOICE, it would expand the range of options for using the reimbursements.
Additionally, the bill includes a cost-sharing reduction appropriation. These typically reduce out-of-pocket expenses for eligible enrollees with the Silver insurance plans in the marketplace — aka, the benchmark. If it becomes law, the proposal would mean that insurers would no longer have to add the cost of cost-sharing reductions to Silver plan premiums.
This is why the nonpartisan Congressional Budget Office estimates a benchmark premium reduction of 11% between 2027 and 2035.
Norris said that the people who would really benefit would be the people who have Silver plans and don’t qualify for premium subsidies.
“Basically, Congress figured out that it would save them money in the long run to fund the cost-sharing up front to spend less in the long run on premium subsidies,” Norris explained. “But the issue is it harms enrollees over time.”
She pointed to the expiration of the ACA’s enhanced premium tax credits, which is already contributing to coverage losses nationwide as premiums rise.
“Right off the bat, the government would save money, because if a person doesn’t enroll (in ACA) at all, the government doesn’t have to pay anything on their behalf,” she said.
As more people become uninsured, physicians warn that the cost of uncompensated emergency care shifts onto providers and, eventually, consumers. Hospitals negotiate higher rates with private insurers, and disruptions in coverage through programs like the ACA and Medicaid can ultimately drive up private insurance premiums.
“The healthiest person today could suddenly be in need of six-figure medical care next week,” Norris said.
Politics of health care policy
Wittman may be among Virginia’s more vulnerable Republican incumbents, due in part to health care changes his party has supported over the past year, as well as shifting demographics in his now less reliably red district. He was, however, one of 17 Republicans nationwide to support extending expired ACA tax credits earlier this year. He framed it as a temporary solution.
The configuration of every congressional district in Virginia could also soon change, pending the outcome of a statewide redistricting referendum set for Tuesday.
The Mercury reached out to all 11 members of Virginia’s congressional delegation for comment on the Miller-Meeks bill and broader questions about health care affordability and access.
Wittman was the only Republican to schedule a call.
Among Democrats, U.S. Reps. Jennifer McClellan, of Richmond, Don Beyer of Alexandria, Bobby Scott of Newport News, and U.S. Sen. Mark Warner — who is up for reelection this year and whose chamber will take up the bill next — weighed in.
Beyer described Miller-Meeks’ bill as “a way to circumvent the Affordable Care Act,” while Scott said his GOP colleagues “don’t understand arithmetic” because removing healthier individuals from the ACA pool can drive up costs for those who remain.
McClellan said the bill “lets (the GOP) avoid the hard work of actually ensuring everybody is covered.”
Warner said he understands the concept behind the proposal and had been warmer to it earlier in his political career.
“But the more I see it, if all we do is debate about who gets covered and who doesn’t get covered, we’re never actually going to get to ‘how to keep bringing down costs,’” he said.
Miller-Meeks’ bill will ultimately need support from 60 of the Senate’s 100 members to advance to President Donald Trump’s desk.
If Democrats make gains in this year’s elections, restoring the ACA tax credits would be an early priority, lawmakers said. However, reversing the broader health impacts of H.R. 1 could take longer, Beyer said, noting that it passed under unified Republican control and may require a Democratic trifecta to undo.
“We’re going to have to live with it for at least the next three years,” he said of Trump’s remaining term in office.
A Democratic wave in the 2018 congressional midterms came a year after a failed Trump-led effort to repeal the ACA. This year’s midterms arrive with Trump back in the White House and a year after he pushed the reconciliation bill that hospitals warned against.
Polling so far indicates that health care access and affordability remain top concerns for voters across the political spectrum — setting up this year’s elections as a litmus test on the issue.