From the 'donut hole' to lifetime limits, here are other key Obamacare provisions in danger

A repeal of the 2010 Affordable Care Act would not only potentially cost more than 1 million Pennsylvanians their health care coverage, but other guarantees and consumer protections also would end.

It's a situation health care and financial experts said could have a catastrophic impact on the state's economy. 

Here's a look at what else could end if the Affordable Care Act is repealed. 

More:Is Pennsylvania ready for 'drastic impact' on health care if Obamacare is repealed?

Medicare Part D benefits improvements

Those benefits include reducing the so-called Medicare Part D drug coverage gap known as the “donut hole,” reducing the coinsurance coverage gap for prescriptions from 100% to 25% and requiring drug manufacturers to provide a 50% discount on the price of brand-name and biologic drugs in the coverage gap.

In 2015, about 297,000 Medicare beneficiaries each saved an average of about $1,000 on their prescription drugs, according to U.S. Health and Human Services Department data. Prior to passage of the ACA, Medicare beneficiaries paid 100% of the cost of their drugs when in the coverage gap. 

The Pennsylvania Budget and Policy Center, a nonpartisan policy group, estimated that prescription drug costs in the state would rise $226 million for seniors without donut hole coverage. 

The law also includes provisions that prohibit Medicare Advantage plans from imposing higher cost-sharing requirements than traditional Medicare for chemotherapy, renal dialysis, skilled nursing care, and other services deemed appropriate by the U.S. Secretary of Health and Human Services. This prohibition was extended to most Medicare-covered services

Medicare cost savings achieved in the Affordable Care Act would be eliminated, resulting in increased Medicare premiums and deductibles for beneficiaries and accelerate insolvency of the Medicare Hospital Insurance Trust Fund, according to KFF.  The Congressional Budget Office estimated repeal of the ACA Medicare Advantage payment changes would increase Medicare spending by about $350 billion over 10 years (2016-2025). 

Coverage for preventative services

Under the Affordable Care Act, most group and non-group plans must cover preventive health services without cost-sharing for consumers. Those services include flu shots, an adult and child annual well visit, cancer screenings, pregnancy services, contraception, well-child visits, immunizations, and routine HIV screening.

Uncompensated hospital costs 

If more people without insurance seek care in emergency rooms, Pennsylvania hospitals — already hobbled by losses related to the coronavirus pandemic — would see their uncompensated care losses doubled, according to the Pennsylvania Budget and Policy Center.  

Uncompensated care includes bad debt from unpaid hospital bills and charity care written off by health systems.

According to the Pennsylvania Department of Human Services, hospital and healthcare system losses attributed to uncompensated care in the state dropped from $1 billion to $731 million between 2014 and 2017, as the number of uninsured state residents dropped. 

Hospital in rural areas of Pennsylvania would be significantly impacted financially if uncompensated care costs rise again, according to the Pennsylvania Budget and Policy Center, a nonpartisan statewide organization. 

Employee health benefits

Employees at businesses with 50 or more full-time workers could lose health benefits, which employers are required to provide or pay a tax penalty.  

Employers also could impose waiting periods for new hires before health benefits begin beyond 90 days, the current maximum time limit under Affordable Care Act. Prior to the health care law, in 2009, 29% of workers waited longer than three months for health benefits, according to KFF. 

Under Obamacare, premium increases employer plan coverage grew at a slower pace.

The average premium for Pennsylvania families with employer coverage grew 5.1% per year from 2010-2015, compared with 7.3% over the previous decade, according to the U.S. Health and Human Services.

Assuming Pennsylvania premiums grew in line with the national average in 2016, family premiums in Pennsylvania are lower today than if growth had matched the pre-ACA decade.

Annual and lifetime benefit limits

Under the ACA, insurers cannot set yearly or lifetime limits on health care coverage, a consumer protection that impacts more than 4 million people in Pennsylvania, according to federal data.

Out-of-pocket cost sharing caps

The ACA limits the amount of money individuals must spend out-of-pocket annually for health-care related costs. For 2020, the annual out-of-pocket maximum is $8,150 for an individual and $16,300 for family. Prior to the law, in 2009, 19% of covered workers had no limit on out-of-pocket expenses and not all expenses counted toward the limit, the KFF said.  

After an enrollee hits the out-of-pocket limit, the insurer pays for all essential benefits, as long as the patient stays in-network.

Substance abuse treatment

According to Pennsylvania data, the expansion of Medicaid has helped many individuals with opioid-use disorders get treatment and medical care. Substance abuse treatment is among the 10 essential health benefits insurance plans must provide with no additional copays or cost-sharing. 

In 2017, 118,000 Pennsylvania residents received health care for substance abuse disorders through Medicaid, according to the state.  

Counties with the most number of residents on Medicaid who accessed treatment are Philadelphia (31,811), Allegheny (11,139), Delaware (4,587), Montgomery (3,601) and Berks (3,430), according to state data.

Before the Essential Health Benefits requirements took effect in 2013, 45% of non-group health plans did not cover substance abuse disorder treatment, according to to KFF.  Three years later, KFF found that people with Medicaid were twice as likely as private insured individuals to have received treatment.

Minimum medical loss ratio rebate

Under the ACA, insurance companies must spend most of the premiums they collect from consumers on healthcare-related expenses. In the large group market, including Medicare Advantage plans, the threshold is 85/15; in the individual and small group market its 80/20, meaning that insurance companies must spend at least 80% to 85% of premium income on medical care and health care quality improvement with the remaining amount for administration, marketing and profits.

If insurance companies fall below the the minimum medical loss ratio thresholds, they must provide policy holders with a rebate.

In Pennsylvania insurers had to pay $181.8 million last year in consumer rebates, according to KFF. Nationwide, more than $5 billion in medical loss ratio rebates were issued from 2012 to 2019 based on insurer financial results from the 2011-2018 plan years, KFF said.