As my colleague Olga Khazan notes, even near-elderly people who have employer-based coverage are at risk, because without an employer mandate and with exchange tax credits, some employers will drop their insurance plans. And of course the employers with the greatest incentive to drop coverage will be those with the most expensive employees to cover—including near-elderly low-wage workers.
Republicans behind the AHCA have known about these challenges for a while, and have done their best to spin them as positives. House Speaker Paul Ryan has defended the plan against criticism of the CBO’s estimates of coverage losses, saying that “this report confirms that the American Health Care Act will lower premiums and improve access to quality, affordable care. CBO also finds that this legislation will provide massive tax relief, dramatically reduce the deficit, and make the most fundamental entitlement reform in more than a generation.” Ryan acknowledges the concerns about coverage losses, but recasts the losses as an expansion of choices that reduces cost.
It’s tempting to buy Ryan’s optimistic spin, or temper it by writing off huge premium spikes as uncharacteristic bits of collateral damage for an otherwise useful plan to control costs.The truth of the CBO report, however, is that the entire mechanism of the AHCA’s savings and premium reductions for healthier and wealthier people lies in making coverage too expensive for older, sicker people with less money. Most of the budgetary savings come from cuts to Medicaid funding and the replacement of the Obamacare premium tax credit with a much less generous credit, both of which will lead to less coverage among this older population. And most of the out-of-pocket savings for people who can afford coverage by 2026 rely on expensive enrollees just disappearing from health-care markets. Attrition among near-elderly people with low incomes isn’t an ancillary effect of Republican policy here; rather it is the engine that makes the rest of the bill work.
The irony is that the mid-aughts health-reform momentum that gave the country the Affordable Care Act put the plight of near-elderly people at its center. For decades, researchers have noted that one of the key turning points in a person’s health-care experience is when they turn 65 and are guaranteed Medicare coverage. For many people, that age arrives as an oasis in a health-care desert. In 2004, almost a quarter of all people between 55 and 64 who made less than 200 percent of the federal poverty line were uninsured, a statistic that led Urban Institute and Kaiser Family Foundation researchers to reach the following conclusion 13 years ago:
Extending coverage to this group could be done either through providing access to Medicare, or creating a new group purchasing arrangement. Expanding Medicaid to even subgroups of the near elderly seems less feasible at this time given that the near elderly are a high-cost population and states are struggling to maintain their programs’ coverage in the face of unparalleled fiscal crises. Alternatively, tax credits for the purchase of non-group health insurance are unlikely to help many of the near elderly unless the value of the credit is substantially adjusted for age or health status.
Without employing some of the options outlined in that report—the Affordable Care Act focused on Medicaid expansion and an adjustable tax credit—the AHCA will likely increase mortality among near-elderly people. Researchers have found that people between 55 and 64 who are uninsured are significantly more likely to die than their insured peers. That much should be obvious, as 65 is a somewhat arbitrary age for health purposes, and often the advance of age-linked disorders comes earlier. The median age of several cancer diagnoses—especially for people of color—often comes in the near-elderly range, and heart disease, diabetes, and hypertension often first manifest themselves during this range. And as the opioid epidemic grips the country, the risk of death from overdose is increasingly rapidly among the near-elderly.