Some Republicans have been thinking about an Affordable Care Act budget reconciliation measure that could keep commercial health insurance subsidies roughly comparable to the 2017 level over the next few years.
Related: Trump courts governors, health insurer CEOs
A draft leaked Friday shows that, in a world created by that proposal:
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Premium tax credit support could stay about the same.
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A new state grant program and new benefits package rules could offset the effects of eliminating the ACA cost-sharing reduction subsidy program.
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One major target of insurers’, employers’ and brokers’ wrap would be a cap on the tax exemption for employer-sponsored health benefits.
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President Donald Trump is preparing to give a major address tonight to a joint session of Congress. He has said he will discuss his administration’s efforts to revamp the current Affordable Care Act commercial health insurance programs and rules.
Republicans have been talking for months about wanting to overhaul the ACA premium tax credit system and the ACA cost-sharing subsidy program, but numbers have been scarce.
The California Hospital Association has posted what is believed to be a draft of a proposal some Republicans were reviewing Feb. 10.
There is no guarantee whether anything Republicans formally propose will look like the leaked draft. Some Republicans have said they object to major components of the kinds of proposals outlined in the leaked draft.
Related: GOP Obamacare plan suffers blow with rejection by key Republican
Another source of uncertainty is how much Republicans will stick with congressional procedural traditions. The new leaked draft consists of a collection of proposed changes to ACA spending and revenue provisions, not a full effort to repeal and replace the ACA, or any major component of the ACA.
The leaked draft is modest in scope because Republicans have just 52 seats in the Senate. Under traditional Senate rules, Republicans need 60 supporters to get an ordinary bill to the Senate floor for a vote, but just 51 supporters to get a budget measure to the floor.
The Trump administration and some Republicans in Congress have expressed impatience with traditional procedural rules, and they might develop new methods for changing federal health policy.
Continue on for an analysis of what might happen if the changes proposed in the leaked draft became law.
In the leaked draft world, more people might get a somewhat smaller premium tax credit subsidy. (Photo: Kay Taenzer/Thinkstock)
Inside the leaked ACA replacement draft
Here is a look at some of its major provisions.
1. Tax credits
If the changes proposed in the leaked draft became law, the draft would replace the current income-based Affordable Care Act premium tax credit system with a new, age-based tax credit. The new tax credit could be used to pay for off-exchange coverage as well as for exchange plan coverage.
Internal Revenue Service figures show the federal government spent about $3,800 per enrollee on premium tax credits in 2015.
The median age of an exchange plan enrollee is about 45, according to Enroll America, an exchange enrollment support program. The tax credit described in the leaked draft would provide a 45-year-old with $3,000 per year in premium.
Although the value of the median tax credit might be lower, the total amount of tax credits paid to insurers for covering individual health enrollees might be about the same, because the tax credit would be available to users of off-exchange individual coverage as well. Today, roughly one-quarter of the users of individual major medical coverage get their insurance outside the exchange system.
2. Other subsidy programs
The leaked draft would eliminate the ACA cost-sharing reduction subsidy program. It does not appear to affect the existing ACA risk-adjustment program, which is supposed to use cash from individual and small-group health insurers with enrollees with low risk scores to compensate individual and small-group insurers with enrollees with high risk scores.
The ACA itself calls for the ACA reinsurance program, which has used cash from a wide range of private health coverage providers to help providers of individual coverage pay the bills of individual enrollees with catastrophic claims, to expire after 2016.