A federal Republican bill to repeal and replace Obamacare was introduced on Monday, but the future of health care remains unclear, local doctors and medical experts say.
“The fight starts now,” said Dr. John Vitarello, a cardiologist in Frederick. “And I hope there’s some maturity in this, because at the end of the day, it’s the patients that will suffer.”
The new bill, titled the American Health Care Act, fulfills a Republican promise to repeal the Affordable Care Act, known as Obamacare.
Since the ACA was signed in 2010, Democratic and Republican lawmakers have clashed. The law has weathered filibusters, Supreme Court challenges, and more than 50 repeal efforts in the U.S. House and Senate.
The American Health Care Act differs from the ACA in several key ways. Most significantly, it removes the individual mandate — a requirement that people who can afford it have health insurance, or pay a monthly tax as penalty.
It also changes how subsidies are distributed to health care purchasers. Under the ACA, tax credits are distributed based on income and the cost of health care plans where an individual lives.
Under the proposed Republican plan, tax credits would be fixed and based on age. A buyer younger than 30 would get a $2,000 tax credit, with increases per decade of age. Buyers older than 60 would get $4,000.
Some Frederick County doctors support removing the individual mandate, citing higher insurance prices some consumers experienced under the ACA.
“What’s happening with the individual mandate is, the deductible is so high, individuals avoid going to the doctor for anything,” said Dr. Julio Menocal, a family medicine doctor in west Frederick.
Vitarello agreed that rising prices hurt private-sector consumers whose insurance costs weren’t offset by subsidies, largely based on income. He said Obamacare became more problematic after three major health care companies pulled out of the government exchange, limiting options.
“Our prices doubled, but now these three major carriers are gone,” he said. “So, Obamacare is like having an airline ticket while there’s no plane, and the airline no longer exists.”
At the same time, he said, removing the individual mandate could cause problems later.
“I don’t think that’s wise because to keep costs down, you need healthy, young people to be in it,” Vitarello said. “They’re not going to be contributing a lot to the cost of health care because they’re not going to get a bypass, they’re not going to get a pacemaker and they’re going to be pretty much low spenders.”
The proposed bill includes a “continuous coverage incentive,” letting insurers charge customers a 30 percent surcharge if coverage lapsed for 63 days or more.
Critics say that’s not enough to pressure younger, healthier people to buy insurance. Otherwise, premiums will rise for older or sicker individuals.
“I’m not quite sure how that formula is going to work for them,” said Dr. Barbara Brookmyer, the health officer for Frederick County. “I would expect many who are healthy would choose not to have insurance, because we can’t predict today whether we’ll get in a car crash or be diagnosed with cancer.”
Under ACA rules, providers cannot charge older customers more than three times what they charge young adults. But under the American Health Care Act, insurers could charge up to five times as much.
According to Brookmyer, that change could have a big impact on Frederick County residents, a large number of whom are senior citizens.
“Even when people qualify for Medicare, sometimes they only get entitlements for the hospitalization part of care,” Brookmyer said. “So, whatever care they get out of the hospital, they have to pay for that. And if it’s up to five times [as much], it’s going to make it really unaffordable.”
Rich McQuarrie, a physical therapist who co-owns a Braddock Heights outpatient physical therapy clinic, called the change an unfair punishment for older consumers.
“To get penalized for living is a problem,” he said.
Brookmyer expressed concern that higher premiums — which she expects under the Republican health care proposal — would exacerbate the high cost of living in Frederick County. A 2014 report from the United Way of Central Maryland found that a single adult in the county needs to make $31,536 a year to afford bare necessities.
Data from the Maryland Health Care Commission suggest that government tax credits under the GOP plan might not fully cover health care costs for Frederick County residents, or Marylanders in general.
In 2012, Maryland residents spent an average of $8,397 per capita on personal health care, including hospital stays, prescription drugs and doctor’s visits.
The ACA’s sliding scale sometimes offset those costs for lower earners. Under Obamacare, a 60-year-old in Frederick earning $20,000 annually would get an $8,800 tax credit, according to an analysis published Tuesday by Kaiser Health News. The same 60-year-old would be capped at $4,000 under the GOP plan.
However, unlike the ACA, the new proposal would let higher earners qualify for tax credits.
A 27-year-old in Frederick making $50,000 could get a $2,000 tax credit under the Republican plan, but not under Obamacare.
Most doctors didn’t expect their patients to be affected by the new plan, based on Monday’s draft.
McQuarrie, who primarily treats middle-aged and older adults, said most of his patients are middle class and might benefit from reduced costs or higher tax credits under the GOP proposal.
Menocal didn’t anticipate major changes. While Medicaid patients make up about 70 percent of his practice, he said, the proposal likely wouldn’t affect them, even though it will gradually roll back expansion to the Medicaid program.
Under the new plan, states that expand Medicaid would get the same levels of federal funding until 2020. Funding would be reduced for people who left the program, then re-enrolled, or who became eligible in 2020.
The proposed bill would place new limits on Medicaid. The plan suggests capping federal funding levels based on how much each state spent per enrollee in 2016.
About 25.8 percent of Frederick County residents, or 62,715 people, were insured through public coverage, including Medicare and Medicaid, as of 2015, according to U.S. Census Bureau estimates. In 2010, 18.8 percent of the county’s residents were insured through public coverage.
While Brookmyer said there was a reasonable basis for the federal government to limit Medicaid spending, it could hurt states later, especially if health care costs rise past 2016 levels.
“It’s saying, ‘Well, we’ll give you so much per person and you’ll have to make it work,’” she said. “The concern is that the per-capita rate they select is not the one that will cover both preventive care and more critical conditions.”
Vitarello was concerned that Medicaid benefits could gradually decrease if state lawmakers do not prioritize the program. But overall, he supported the new GOP plan, citing aspects of the ACA that he felt placed an unjust burden on patients.
He and Menocal opposed the individual mandate, which forced health care buyers to subsidize services they didn’t need.
“You can’t require a 60-year-old man to be paying for coverage for a well woman exam,” Menocal said.
“Under Obamacare, you had people who were 62 years years old and they had to pay for maternity care or contraception. Meanwhile, well, my wife’s been dead for four years," Vitarello said, referring to a hypothetical situation. "I don’t have any need for maternity care or contraception. Why am I paying this? Well, it’s being done to offset the costs for young females.”
Critics argue that the new plan will push up premiums and hurt lower income consumers. But Vitarello said he would rather have tax subsidies that let patients pay for an affordable product, rather than a health care plan that forces heavily subsidized insurance.
Premiums under Obamacare rose substantially from 2014 to 2017, though 84 percent of consumers received financial subsidies to offset those costs, according to the Department of Health and Human Services.
The increases largely affected remaining consumers and those who bought insurance directly, rather than getting it through employers or the government.
Under the proposed GOP plan, insurers can’t reject or charge more to people with existing medical problems. It also lets young adults stay on their parents’ insurance plans until they turn 26.
Despite those assurances, the Maryland Hospital Association and several national health groups oppose the bill.
“Without estimates from the Congressional Budget Office of the impact on the federal budget or, more important, the impact on the number of Marylanders with health care coverage, we, along with the rest of the nation’s hospitals, must oppose the bill,” MHA President Carmela Coyle wrote in an email.”
The Associated Press contributed to this story.