GOP tax bills threaten health care for many in Pa., N.J., advocates say

Dec. 06--Just months after congressional Republicans failed to repeal the Affordable Care Act, local advocates are scrambling to decipher what the GOP tax overhaul plans now pending in Washington could mean for the health care of seniors, children, and the disabled in Pennsylvania and New Jersey.

Much of their concern centers on how tax reform could push insurance premiums up and enrollment down. Unrelated news on Wednesday raises the potential stakes: The latest tallies for enrollment through the ACA insurance exchanges, while rising, look unlikely to match sign-ups in past years.

Comparisons are tricky because the Trump administration shortened the open enrollment season from 92 days last year to 45 days this year, while also slashing budgets for advertising and support staff. The deadline to purchase insurance on the exchanges is Dec. 15. Normally there is a rush at the end of the enrollment period.

Based on the proportion of the season that has passed, however, the 3.6 million people that chose plans through Saturday is barely 40 percent of enrollment at the same point last year. New Jersey (104,142 so far this season) and Pennsylvania (161,388) are slightly below that pace.

Advocacy groups believe that confusion over the ACA's future has played a big role, and news from Washington has been adding to it. The Senate over the weekend passed a tax reform bill that dumps the penalty for those deemed able to afford health insurance but do not buy it.

Dropping the mandate was not part of the House version of the bill, although it may return as the two versions are reconciled for Trump's signature. But the House bill, which was approved three weeks ago, eliminates the itemized deduction for medical expenses.

"The impact of these cuts would be incredible on older Pennsylvanians," Ray Landis, advocacy manager for the state AARP, said in a conference call with reporters on Tuesday. While most Americans do not itemize deductions on their tax returns, people with higher medical expenses, such as seniors, are more likely to do so. An AARP analysis of IRS data found that 311,000 Pennsylvania households deducted an average of $11,000 in 2014. (In New Jersey, 387,000 households deducted an average $8,800.) The analysis did not examine the impact of a GOP plan to change deductions for state and local taxes, which disproportionately affects high-tax states like New Jersey.

The Congressional Budget Office (CBO) last week projected that elimination of the mandate that most people carry health insurance would lead to an additional 13 million uninsured by 2025, and would drive premiums up another 10 percent in 2019 in the exchanges set up by the Affordable Care Act (ACA). Most people who buy insurance on the exchange are eligible for subsidies that increase with premium price. But perhaps 20 percent -- and everyone who purchases individual coverage off the exchange -- would pay more.

Marc Stier, director of the Pennsylvania Budget & Policy Center, pointed to state-by-state impacts of the Senate bill from the Center for American Progress, a left-leaning policy institute. It says that 505,000 more Pennsylvanians would be uninsured in 2025 and average annual premiums for an unsubsidized family of four would rise $2,300 in 2019, not counting other market trends. (Uninsured New Jersey residents would increase by 325,000, with annual premiums up an average of $1,650.)

The biggest worry for health-care advocates, however, is what could be coming in future years, especially for Medicaid, the government program for the poorest Americans, including seniors in long-term care who have spent down their savings. The CBO estimated that the Senate bill would add nearly $1.5 trillion to the deficit by 2027, and Republicans have made no secret of their desire to reduce that by cutting so-called entitlement programs such as Medicaid. They came close to a historic reduction in Medicaid over the summer in one of several ill-fated versions of Obamacare repeal.

"We're really concerned about what the Senate bill will [mean] when it comes to health care," Maura Collinsgru, health care policy director at New Jersey Citizen Action, said in an interview.

The ACA's Medicaid expansion has made treatment for opioid addiction available to many more who need it, though the presidential task force that was headed by Gov. Christie said additional access is needed. Medicaid also provides health insurance to poor people whose myriad medical problems make them more vulnerable to opioid addiction, which frequently starts with a doctor's prescription. In Pennsylvania alone, 124,000 people have received treatment for a substance use disorder since Medicaid was expanded in 2015, said Shelby Kehoe, a youth advocate at Mental Health Partnerships, formerly the Mental Health Association of Southeastern Pennsylvania.

Cutting Medicaid also would harm seniors, especially in New Jersey, which spends a higher proportion of its Medicaid dollars on the elderly -- mainly paying nursing home fees -- than all but two other states.

Pennsylvania is No. 2 among the states for the proportion of Medicaid that it spends on people with disabilities. Yet thousands of adults with intellectual or developmental disabilities are unable to get coverage, an Inquirer and Daily News series this week has shown.

Neither state could make up for the lost federal funding, so needy groups -- the disabled, elderly, children -- would compete for whatever is available. "Eventually, states are going to have to figure out how to cut Medicaid when there is less money," said Antoinette Kraus, director of the Pennsylvania Health Access Network.

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