Act Now to Protect Healthcare for Americans with Kidney Disease!

Major health care reform in the U.S. right now could affect YOU. In fact, the Senate may vote as early as this week on its “Better Care Reconciliation Act” (BCRA). The BCRA would replace the Affordable Care Act (ACA), which some call “Obamacare”. If passed, this new law would make sweeping changes to health insurance for ALL Americans. Those with chronic illnesses—like kidney disease—would feel the effects most. Some Senators are trying to push the bill so quickly that you may only have days to make your voice heard. At the end of this post, I’ll tell you how to reach your Senator and what you may want to say.

The Congressional Budget Office says that the BCRA will increase the number of Americans without health insurance by 22 million in 2026.

The BCRA would change most health plans that pay for dialysis and the rest of the health care you need. It would not change Medicare, which pays for dialysis or kidney transplants for those who qualify. However, Medicare never pays 100%, so even if you have it, you still need a second health plan. Medicaid, an employer group health plan, or a private health plan would pay the balance that is left. Here are some terms that you will need to know:

• Medicaid: the largest U.S. government health care program - started in 1965 to provide health care to those with very low incomes who were also disabled, seniors, children, or pregnant. Medicaid and the Children’s Health Insurance Program (CHIP) insure 16.7 million Americans. States and the federal government both pay for Medicaid. Each state has its own guidelines for who qualifies and what services it provides. In 2014, the ACA started Medicaid Expansion. States that chose to do this gave Medicaid given to anyone who earned up to 138% of the federal poverty limit ($20,782 for one person; $42,435 for a family of 4). See the map below to find out if you live in one of the 31 states (or Washington DC) that expanded Medicaid. Or, visit this website to learn more.



• Health Insurance Exchange Marketplaces - sites in each state created by the ACA that offer health plans to those who earn too much to get Medicaid and do not have jobs with health plans. In 2017, 12,216,003 Americans got an Exchange health plan. You have one if you bought insurance from www.healthcare.gov.  The plans are “Bronze,” “Silver,” “Gold,” or “Platinum.” A Platinum plan covers the most services and costs the most. ACA rules put limits on the “out-of-pocket” costs like deductibles, copays, or coinsurance these plans could charge you. The ACA had federal subsidies to help pay for Exchange health plans. One person earning up to 400% of the federal poverty limit ($47,520) or a family of 4 earning up to $97,200) could get help to pay for their health plan. Those who earn the least got the most help. Subsides came in 2 forms:

  1. Premium Tax Credits - the federal government pays for part of a bronze, silver, gold, or platinum health plan. You can get this tax credit in advance or claim it on your tax returns.
  2. Cost-Sharing Subsidies - help to pay for out-of-pocket costs. You must have a silver plan (covers 70% of your medical costs), and only those who make up to 250% of the federal poverty limit ($30,150 for one person or $61,500 for a family of 4) can get this help. The federal government pays for it.

  * NOTE: In some states (CA, CO, CT, DC, ID, MD, MA, MN, MS, NM, NY, RI, UT, VT, WA) you can buy an Exchange health plan without using www.healthcare.gov.

• Employer Group Health Insurance – a health plan you or a spouse or parent gets from work.

HOW WOULD THE BCRA CHANGE MY HEALTH COVERAGE?

• Who would be covered?

  This bill keeps the ACA rule that children up to 26 years old can get insurance under their parents’ plans.

• Who would have to buy a health plan?

  The BCRA does not require all Americans to have a health plan or pay a tax penalty (like the ACA does). BUT…the BCRA requires a 6 month wait for someone who does not have a health plan to get coverage after they apply. So, if you find out you have kidney disease and do not have a health plan, you have to wait 6 months before a plan will start to pay for your care. And, if you miss a payment, you will have to wait 6 months before your health insurance will start again. During those 6 months, you will have to pay all of your health care costs—for dialysis, hospital stays, surgeries, everything.

• What would happen to those with pre-existing conditions like kidney disease or being a kidney donor?

  Like the ACA, the BCRA requires states and companies to offer health plans to all. BUT…the BCRA would remove the ten “essential health benefits”after 2019. And, it would put back lifetime and annual caps on how much your health plan would pay for your health care. So, companies could choose NOT to pay for costly things like drugs, lab tests, dialysis, diabetes supplies, transplant, etc. Or—they could charge you a lot more than you pay now. And it will be harder to compare plans’ cost and coverage. Often cheaper premiums mean higher out-of-pocket costs or fewer covered services.

The Congressional Budget Office (CBO) estimates that about half of Americans live in states that will waive essential health benefits. Before the ACA:

• 10% of Americans did not have a health plan that covered prescription drugs.

• 82% of those with an employer health plan had a yearly out-of-pocket maximum.

• 59% of those with an employer health plan had lifetime limits on their coverage.

The BCRA is likely to bring back plans that do not cover essential benefits and that do have caps. This would be a disaster for those with kidney disease.

• What would happen to me if I get my health plan from an Exchange?

The BCRA would cut back the help you may get from the federal government to pay for an Exchange health plan. Instead of helping those who earn less than 400% of the federal poverty limit, the BCRA would drop the help level to less than 350%. ALL help would stop in 2019. And, instead of tax credits going for plans that cover 70% of your health care costs—the BCRA would only cover 58%. So, you would pay a lot more for a health plan that covers a lot less.

This map can help you can see out how this change will impact YOU. Let’s say you live in Lexington County, SC, like I do. Let’s say you are 60 years old. And, you earn $43,875 (375% of the federal poverty limit), and have a silver plan. You would spend 8% of your income for an ACA health plan —but 36% under the BCRA—and, it would cover less. In rural areas like Maine and Alaska, you would have to spend almost half of your income on health care premiums under the BCRA.

Are you over age 59? The BCRA could cost you a lot more. ACA rules do not allow Exchange health plans to charge older people more than three times what younger people are charged. The BRCA will raise this to five times more than what younger people are charged.

• What would happen to me if I have a health plan through my employer?

A company that operates in more than one state can pick a health plan from any state to use for all employees. Your employer could choose a plan from a state with NO essential health benefits. It could choose a plan with annual or lifetime caps—or, all of the above. Even if YOU live in a state that does not approve these changes, you would be stuck. The BCRA also lets large employers not offer health plans. So, you might not be able to get a plan through work at all.

• What would happen to me if I (or someone I love) is on Medicaid?

The BCRA makes a massive change to the way Medicaid is paid for. Now, states get federal funds based on how much they spend to cover people. All who qualify can get Medicaid. If costs rise (more people need it or there is new, more costly care), states get more money. BCRA would limit how much each state can get for Medicaid. The amount will go up only based on the Consumer Price Index for health care + 1% through 2025. After 2025, it will only go up based on the Consumer Price Index for all goods (which tends to be far lower). Even worse, the BCRA also lets states get Medicaid funding in a “block grant”; a fixed sum for all of their Medicaid costs for 10 years. This sum cannot go up even if more people need Medicaid.

States will have no choice but to make deep cuts. This may mean that your state will not pay for transportation to dialysis or home health care. New technology, like artificial implantable kidneys and portable wearable dialysis, will be too costly. The Congressional Budget Office concludes that the BCRA will cut $772 billion from Medicaid and 15 million fewer Americans will have Medicaid by 2026. If you have Medicaid because you live in a state that expanded it, the BCRA will keep this program until 2020. After that, the program will be cut back—and will end in 2023. Your state may drop you or your fellow kidney warriors from Medicaid when it gets less funding for your care. The BCRA also says states can ask those on Medicaid to re-apply every 6 months (or even more often). If you or a loved one has ever applied for Medicaid, you know what a paperwork nightmare it can be. Under the BCRA, you might have to do that each month. Imagine how stressful that would be!

• Would the BCRA make my health care cheaper?

  If you have kidney disease, there is nothing in the BCRA that will lower your costs. You may also have other illnesses like diabetes or high blood pressure. You need regular (and costly) health care. You may need dialysis every week of every year or a transplant. You need to see your doctors (lots of them!). You need to take lots of (costly) prescription drugs. You need lab work. You need surgeries for fistulas and PD catheters. You may be in the hospital. You may need physical therapy. You may need medical transportation. You may need substance use or mental health treatment. You will need to pick a plan that will cover all of your health care needs and treatments. With the BCRA, your health care premiums may dramatically rise to get a plan that will cover all of your needs.

• What would happen to public health programs that help kidney disease patients?

  The ACA created the Prevention and Public Health Fund to create programs to improve the health of Americans. This fund pays for things that help those with kidney disease, such as chronic disease self-management, diabetes, and prevention of heart disease, stroke, and infection. The BCRA gets rid of the fund.

Because of all of these issues, NO patient, health professional or health provider groups support the BCRA. NONE of these groups were involved in writing the BCRA. In the couple of days since the BCRA was released last Thursday, the American Medical Association, American Academy of Pediatrics, American Psychiatric Association, Children’s Hospital Association, AARP and others have come out to strongly oppose this bill. Six doctor groups oppose it, stating the “*bill contains provisions that would do great harm to patients by repealing and undermining essential coverage and key patient protections established by the Affordable Care Act **and make health care unaffordable for millions of Americans.”

In June 2017, 120 patient groups (including the Polycystic Kidney Disease Foundation) came together to oppose cuts to Medicaid in health care reform like those in the BCRA. The National Health Council speaks for people with chronic diseases and their families and includes the American Kidney Fund and National Kidney Foundation. They oppose the BCRA, stating it “will have a devastating impact on people with chronic conditions, who will pay more for access to less care.” The National Kidney Foundation (NKF) says “this bill allows states to eliminate the essential health benefits currently provided under the Affordable Care Act, and permits insurers to discriminate against people with pre-existing conditions by not covering vital medications and treatments they need to manage their conditions. For kidney patients, this could include treatments such dialysis or transplantation and medications.” The NKF went on to say, as state Medicaid budgets are tightened across the nation, states may look to reduce the populations they cover and eliminate expensive, but critical, benefits like dialysis treatments.

Since the start of the ACA, there have been valid concerns about how good a job it does. People may have high deductibles and co-payments. Each year, there are fewer Exchange plans to choose from. There are ways we could improve the ACA to help you with kidney disease. But, I was a renal social worker before the ACA came out. I worked with patients who could not find any health plan they could afford. I know how impossible it was for someone under 65 to find a Medicare supplement, or a health plan that was affordable at all. Before the ACA, there were no good options for those with kidney disease who needed a health plan but made too much to get Medicaid. Dialysis and kidney transplant patients often reached their annual or lifetime caps on their health plans.