Mitch McConnell | File Photo

As the fate of the Affordable Care Act and health care for millions of Americans hang in the balance, U.S. Senate Majority Leader Mitch McConnell visited the White House Wednesday afternoon to discuss the proposed repeal of the ACA with President Donald Trump.

McConnell, R-Ky, still plans to hold a vote on the measure in the U.S. Senate next week. The senator initially had wanted to repeal and replace the ACA, informally known as Obamacare, but could not convince enough colleagues to support the replacement bill he introduced in late June.

But the straight repeal bill, too, is headed for failure.

Three Republicans – Susan Collins, R-Maine; Lisa Murkowski, R-Alaska; and Shelley Moore Capito, R-W.V. – already said they could not vote for the measure. McConnell can lose only two Republican votes.

Moore Capito said that without a replacement plan, she worried about the impact of people who have gained Medicaid coverage through the ACA, “especially in light of the growing opioid crisis.”

The nonpartisan Congressional Budget Office said late Wednesday that McConnell’s latest proposal would decrease deficits by $473 billion through 2026 – but also would leave another 32 million Americans without health insurance and would cause insurance premiums to nearly double.

Nearly 80,000 Kentuckians get their insurance on the federal health exchange, which was a central part of the ACA. Insurers have asked Kentucky officials to be allowed to raise their rates for next year by up to 47.7 percent. The state is expected to make a ruling on the requests next month.

Insurer struggles

Many insurers, including Louisville-based Anthem, have said the customers they have gained through the exchanges have been sicker – and more expensive – than expected, and that their insurance premiums have not been nearly enough to pay for their care. Humana said it lost hundreds of millions on ACA customers last year and will not offer exchange plans next year. The insurer posted a loss in the fourth quarter of last year – but was profitable for the whole of 2016.

Anthem, the only insurer to offer exchange plans in all 120 Kentucky counties, declined to comment on this story, referring questions to an industry group, America’s Health Insurance Plans. An AHIP spokeswoman did not want to comment on the latest developments, saying only that the organization remains committed “to working with every policymaker and the administration to ensure the short-term stability and long-term improvement of health care in our nation.”

AHIP CEO Marilyn Tavenner told senators in February that while the ACA has expanded coverage to 20 million Americans, “certain parts of the (law) have not worked as well as intended.”

She told legislators that they can stabilize the market through various steps including the continuation of subsidies to help people buy insurance and encouraging younger people to sign up for coverage by allowing insurers to charge older, sicker Americans five times as much as younger, healthier Americans. The ratio currently is 3-1.

The American and Kentucky Hospital associations could not be reached.

Dustin Pugel, research and policy associate at the Kentucky Center for Economic Policy, said that Congress also could make more subsidies available to people who so far have been unable to afford health coverage.

Some people – those who are employed but do not get health benefits through work and who earn more than four times the federal poverty level – do not qualify for federal health care subsidies on the exchanges. Expanding subsidies to people making four or five times FPL would bring additional people into the individual market, Pugel said.

In addition, he said, Congress could allow Americans who are 55 to buy their way into Medicare, the government insurance program for the elderly. Typically, Americans cannot get Medicare until they turn 65. Allowing people 55 and older to pay monthly premiums to obtain Medicare benefits would improve the risk pool on the exchanges, because some older, sicker Americans are removed.

Medicaid cuts

Dustin Pugel

Pugel said that McConnell’s ACA repeal bill would have an even greater impact on Kentuckians on Medicaid.

The ACA provided expanded Medicaid coverage to states that wanted it, with the federal government picking up most of the cost. Then-Gov. Steve Beshear agreed to allow Kentucky to participate, but Gov. Matt Bevin has asked the federal government to opt out of the expansion, saying it would cost the state $1.2 billion between 2017 and 2021 and that the additional expenditures would jeopardize funding for pension obligations, education and public safety.

The expansion has allowed 475,000 additional Kentuckians to gain Medicaid. About 25 percent of those are covered by Louisville-based Passport Health. In total about 1.4 million people in the commonwealth are covered by Medicaid.

Bevin instead wants to implement a state program called Kentucky HEALTH, which would require people to pay small premiums – as little as $1 per month – and would ask able-bodied recipients to perform some type of work or community engagement. Bevin’s request is pending.

Pugel said that McConnell’s bill would not only eliminate the Medicaid expansion but make significant changes to Medicaid as a whole.

“I hope that we protect that program and build on it rather than make the kinds of massive cuts that have been proposed recently,” he said.

Pugel said that while the proposal to completely repeal the ACA has created some uncertainty, Congress could make cuts to Medicaid as part of the next federal budget.

“As to what comes next, your guess is as good as mine,” he said.